#265 | The Art of Hands-Off Birth with Beautiful One Midwifery

We can always add a vaginal exam in, but we can never take that experience back. So we want to use these skills and this assessment tool in particular, thoughtfully because this matters in any other part of your life, who puts their fingers inside of your vagina really does matter.

And it gives everybody else a false concept of where we're at in the process. None of that matters to the woman's.

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.

We are the midwives from beautiful one midwifery and we have a homebirth practice in San Diego, California. I'm Tiffany I'm Kelly. And we have a really mixed approach in tackling topics all around birth because our background is in in being doulas. That's how we kind of like got our start in the birth world after having our own kiddos. In various circumstances and care models. We both kind of independently were doulas for several years before we pursued Midwifery, and something that I have noticed just as a newer midwife, I was licensed in 2018. We started our practice in 2019. So we've been going at this only for like five years or so. But what I've noticed in that span of time is a huge difference. In midwives who practice with the background of just Midwifery, and midwives who practice at the background of the advocacy piece of being a doula, it has informed almost everything about the way that we approach informed consent and the strategies and taking care of women and really creating a place where they can be empowered in their birth experiences.

Can you can you go a little deeper on that and explain exactly how it's a different you come to birth with a little bit different dynamic Is it is it a little bit more like the power structure is different because of your background or expecting that's

a really big part of it, because so much of our history in birth work is about elevating a mom's desires listening to what she wants, rather than necessarily what we even want for her. And so a big part of the learning curve of ours, as midwives ourselves also was women making decisions that maybe we wouldn't have made for ourselves or that we even as clinicians would be like, well, actually, we would encourage this decision clinically. But at the end of the day, it is always our clients decision. What they want to do with that, and so getting more comfortable with that, certainly looking around in the midwifery community, both locally to us, but also even just getting glimpses online. There are definitely practices that are much more uncomfortable with that and they set you know, tighter boundaries for certain decisions. That's what helps them feel safest in their practicing what helps us feel safest in our practicing is informed decision making. So having these types of deep conversations, and then allowing parents to kind of flourish in their role of true decision makers for themselves and their families. I think that's where so much of the transformation of midwifery care, especially lands.

So you're giving the woman the radical responsibility,

like us a whole different distribution of responsibility. Yeah.

Before we get into today's topic, and I know we all want to talk about hands free Midwifery, basically. And you have a lot to share about that. And I'm very much looking forward to asking you questions and hearing about that. I just want to know quickly, we definitely aren't going to get into your birth stories at all. But I do want to know, did you essentially get pulled into this work because you were inspired by your own births or because this work was healing for you, given how your births went?

Both? Yeah, I

think there's a little bit of both there. So I got into birth work after my first was born and honestly I had a hospital birth I didn't really know much. I took a birth class. I ended up having an unmedicated birth and I kind of left field which was wonderful, right? That was like you had the birth you thought you wanted, right? Yes. And I realized how subpar just walking in wanting an unmedicated birth, I realized there was so much more that I wanted to experience. And actually there was so much more than my husband wanted to experience and he felt really railroaded. And that's, it's actually like kind of the dad's perspective, really, that got me into doula work, as I was encouraging other friends who were starting to have babies, to have somebody by their side to even even help their partners. And that just sort of became me at that point. And then it absolutely kind of snowballed from there with my own future experiences with homebirth. From there as well.

So you had to homebirths after that. Yes. Okay. Yeah. And Tiffany? Yeah,

my experience was similar, but I didn't have the information or the support that I needed to actually have the unmedicated birth that I thought I was planning. I thought I was, you know, I thought I was gathering all the information, I thought that I was capable of advocating for myself and the hospital environment. And it so quickly, just turned into the, like the perfect conveyor belt of interventions. And thankfully, it was a relatively smooth, smooth process. And I'm grateful for how it turned out having seen how some of those interventions in my birth could have created a much less desirable outcome. But it was that experience that I was processing with another friend, and she's like, you know, you probably should have had a doula. And I'm like, I don't even know what that is. So that's how prepared I thought I was for my natural birth in the hospital. But when I learned what a doula was, and I was able to reflect on how that role could have changed everything about my birth, just having a person who knows and can help and can advocate. I'm like, I think I'm gonna be that person for other people. And that is, that's what kind of, you know, set me down, doula work trajectory. And then for my second and last kiddo, I had placenta previa. And so navigating a more complicated pregnancy with a more medically necessary planned cesarean completely rocked everything about what I thought my birth experience was, or should be, or what I thought I deserved, or, you know, fill in the blank, it took me many years to like, kind of untangle that experience. But I love the way that that experience has shaped me into a provider who understands what it's like to be on the on that end of birth, where medical intervention is completely necessary, even though it sucks, and getting to walk through some of those experiences with our own clients. is definitely allows me to see how that was an important thing for me to have in my history, too.

Yeah, definitely understand and agree with that. So can we dive in? I mean, why don't we hear what you have to say, on attending women at home? And what hands off means to you?

Yeah, I think what's interesting is that we have some verbiage on our website that talks about being more hands off. And that was one of the most common questions that we would get from people coming into our office and kind of consulting with us interviewing us would be like, what exactly do you mean by that? Because I kind of want your support. I might want it your hands, I might want you to like, rub my back a little bit. How hands off? Are we talking? Right? And I think realistically, it's more medically, hands off in terms of allowing our, our clinical presence to be more of scaffolding and of clinical thoughtful watchfulness, than needing to look at a situation and think, Well, I know how to do these 10 skills that I could do right now. So might as well just do them, right. It's really about understanding the skills, knowing the skills well understanding how to implement and when to implement, but mostly how to sit on that. Right How to not use your hands, assess your you know, history of learning things simply by watching them unfold and physiological birth is something that we consistently kind of turn back to if we were to do nothing, how was birth normally play out? And what what can encourage that and what hinders that? And how can how can we be a part of the encouragement rather than the hindering?

It's the it's the exact opposite of the medical management of birth.

Yeah, and even times when we think it might be necessary, we often have to reevaluate, sometimes debriefing after the birth and thinking, Is there a way we could have done that with less or you know, because we don't want to go from zero Ready to 100 just because there's a potential complication coming, we always want to be looking for ways to restore physiology, restore the power back into the woman and in her body. And there's very, very little in which we actually need to come in and rescue, most of the complications that we end up supporting is just bringing things back into normal really gently. And so I think sometimes, when women evaluate that concept, it's almost impossible to conceptualize, because there's no framework in our society for what that would look like. And most of the information out there about home birth is like, that's great for you, if nothing goes wrong, that's wonderful if you're lucky enough, that you don't have a complication in your birth. And instead, that narrative needs to be swapped for like what Kelly said, What do our bodies do really well on its own? How do we know that? Kelly and I have the really incredible experience of observing that hundreds of time, but most people do not most women do not go in anticipate going into their first birth or their first unmedicated or their first physiological birth with any kind of framework for what that could look like. And so we are having to teach women that constantly to help them envision it, to help them imagine themselves in that place to help them truly trust and take our word for it, that things usually go better when we do less. And that's, that's a long journey for some,

I work with women by teaching them and preparing them for birth. And Trisha was my one of my two homebirth midwives that my own second birth. So Trisha isn't midwife. But I work with the women who show up scared, and they're preparing for birth. And when you're saying all this, I can imagine how they might feel seeing that on your website, because their first thought hilariously is, I can't do this by myself. That's the that is the only way you're going to do this, actually. But that's why we don't even believe in saying language like we are pregnant, even though it was made to be politically correct, because it was there to somehow remind couples that they certainly share responsibility for this birth and this baby. But I'm always afraid it's going to cushion that woman from reality too much. Like you will birth this baby on your own. And we are here to hold you up and support you and attend to you. And you will be able to do this, but we can't deny. And the moment a woman is in labor, her partner feels that more than anyone we cannot deny she is doing it. 100% and he could not even be there. And everything would continue and proceed. Do you want to comment on?

Oh, I'm just agreeing with you like, yes, absolutely. I'm like, you're not alone, honey, like you're not by yourself. You are not meant to do it by yourself, unless that's what you want to do. But it is your work. It really is just your work. And none of us can take that from you. And you shouldn't want anyone to take that work from you. It belongs to you.

Yeah, and I think that's like the crux of it right? Is that this experience, this entire walk and journey that you're on is yours. And so yes, again, you're ideally with a partner who understands and wants to support you in that you ideally have a care provider who is like, I'm on this journey alongside you not telling you, you know, not telling you exactly where to go with it, but just walking with you. But the ownership piece, we have lost that completely with what's just general maternity care in our society. And so it's just such a huge narrative shift. It's the same idea of accepting some of that responsibility. We've been so programmed to give it away, that it feels really other for a lot of people to step into this and to truly own every aspect of it and have it not feel like something you need to be rescued from but something that you can actually find joy in that you can walk through feeling empowered and supported and all of those pieces. But again, it's just such a such a narrative shift that that's why podcasts like this, and when we share birth stories on our Instagram feed as well, like women, most of the comments that we get, I'm like, wow, I didn't know birth could actually be like that. I didn't know, or I want this and I don't I don't understand how my vision of birth is so different than what these other women are experiencing. What do they have that I don't have and it's not anything that they don't think special about these about women who are birthing in their own kind of empowerment and all of that it's it's the narrative kind of around that that that has she lifted for them.

It's a huge responsibility for a woman to take on complete ownership of her birth and her baby. It's not just her body anymore. It's another life that she's responsible for. And this is, of course, why the transition from woman to mother is so massive, because you are no longer ever just you, it is always you and other and you are responsible for that other. And I think so many women just we feel like when we become pregnant, yes, we have this ideal vision of how birth should be we read the healthy normal birth books, we see the good birth stories, we get a little bit educated. And we think that we will just have a nice, easy, you know, hopefully vaginal, hopefully I'm medicated, I'm going to try for this, I'm going to try for that. But you know, I have my birth plan. I've spent some time on it. But we'll just see how it all goes. If I need something, there'll be somebody there to take, you know, take over and step in for me. But that's, this is another kind of birth, we're talking about, like you're talking about No, you have full responsibility for this body this birth this process, it is all you yes, there support teams around you, yes, there's going to be somebody looking out for things that are deviating really far from the normal. But it is not just a walk in and see how it goes. Like,

you know what this reminds me of, sometimes with, with that very notion of women, feeling like they absolutely must have someone else, show them how to give birth or give birth with them or give birth for them. I like to remind them sometimes that even if they try with all their mind, they cannot prevent this baby from being born. It's happening. They actually don't, it's really great when they do learn how to support themselves, but they actually don't have to do anything. It's happening with their participation or not with your participation as their attendant or not it is happening. And once they swallow that reality, this is happening. Now it's like okay, now how can I make this, as you were saying, Kelly, like, there, we ask for a joyful experience here, not just one where we all survive.

Right. And I think we've been given the narrative that state like safety, everybody came out alive is like, that's, that's what we're striving for. Right? That shouldn't be the absolute baseline, right? Like safety should be the low bar. Right? That should be everybody should expect that. And there's just so much more available to women in birth, that we have robbed. We've robbed so many women have that experience in so many families have that type of experience, because because they don't necessarily even know that birth can be joyful, that it can be empowering, that it can be connected and peaceful. And all of these positive words, right that even if it is hard, even if it is painful, even if it is right, you feel like you're clawing your way to the finish line, you can still feel supported, you can still feel all of these positive terms about your birth. But again, this is

it's meant to be transformative birth is meant to transform you and if you are not in an environment where you can allow yourself to really surrender into that process. And just what Cynthia was saying about like it's happening, you have to surrender to it. Yes, you don't have to control it. You don't have to manage it. That's not at all what we're talking about not learning to be not taking responsibility to the point where you have to manage your birth you have to surrender to surrender to the process. And a healthy mom and baby is the baseline is not the pinnacle, which is how it's treated.

I also hope everyone picked up on what Tiffany said earlier. She said sometimes after our birth we reflect on it and we ask ourselves could we have skipped that could we have intervened last and just to underline how extraordinary that is for an attendant or provider or doctor or midwife to attend a birth and go home and reflect on it and ask Did I do right by that woman? Did we do the best we could have. I have my very close friends with Nancy Waner. And I once asked her how many Peasy ostomy She's performed in her nearly 3000 births that she's attended. And she said I've I've only done three but I still regret one of them. Be still don't think I needed to cut that third woman and I thought it has been decades and you're still suffering with this. And then when you think about how thoughtlessly and carelessly so many women experiences, their infections and the doctors aren't really Then on to their next plan for the day, because that's the model that they're working in. But what a world of difference to imagine that your midwives go home and reflect on your birth and ask themselves, if they could have done it any differently. That's really incredible. As

you were saying that something I'm thinking of like a not big regret, but like think reflecting piece on a birth that we did one of our values is not doing artificial rupture of membranes for pretty much any reason we never do it, how we reserve it as a potential to use in a complication and what that complication could be as like kind of gray, like when that would be an appropriate use of that intervention. But we did use it at a birth, where we were having a lot of trouble with pushing baby's heart tones, we could not get it resolved, we thought this baby just needs to be born. And part of what is potential, some a tool that we have is to rupture the membranes. And reflecting on that birth. That was wrong. That was the wrong choice. I regret making that call. I told the I told the client that too, as we were just debriefing about all the things that had happened at that birth, that that was the wrong thing. So even in that moment, where I thought, Oh, here's it, here's a time where I can actually use a tool that I have. I don't think that that helped our situation at all. In fact, it might have caused it to become more complicated. And I probably will not, I probably will think really, really, really hard about ever using that tool again, even in a situation is like we need to do something. So yes, and and we should all as providers, we should all be able to say, I've made mistakes, I've done things that I did not think served the woman the best. And that's a part of me learning and me growing and me becoming a better provider. I'm not going to get it right all the time. And that dialogue, that reflection that processing should be a part of, of all providers, either who you work with, or who you work for with your clients.

Can you just talk us through a few more scenarios, common scenarios, maybe less dramatic than something like that. And things like vaginal exams, fetal heart rate assessments, even just touching a woman or speaking to a woman entering her space and labor is an intervention. So can you talk us through how you keep on the back seat and still kind of keep an eye out and still kind of keep an eye on labor and understand when you should intervene? And when you shouldn't and what that looks like when you do?

Yeah, and I think you've just touched on such an important point is that almost anything we do as an intervention client calling us and saying we would like you to come us showing up, us even being drunk, knowing that, you know, we're driving on our way is an intervention of some kind, right. And so walking into a birth space has to involve so much humility, and so much awareness of what the type of you know, even body language that you're bringing into it, how we're setting up our equipment, when we show up, and how we are offering to listen to baby how we are, you know, touching or rubbing Mom's back when we first get there and kind of talking to her and connecting with her. But all of those things we actually talk about beforehand. So when we go around 36 weeks, we'll go to a client's house and have what's called the home visit, and talk them through just generally, obviously, we don't know how things are really going to play out the day of but what to anticipate about communication and labor, but also what to anticipate about us showing up how we set up our items. What we are, what we are bringing, we let them take a peek at some of those things so that it feels less jarring when they're seeing us potentially pull out some resuscitation equipment just to keep out and prepared should those things be needed. And I think setting the stage simply for what to expect is a huge part of decreasing a bit of that hubbub that happens when we when we do show up. But one of the biggest pieces that we have seen is, is the idea that when we show up, a lot of women are like, well, this is when I'll get my vaginal exam and figure out where I'm at in labor. And then we can decide what to do from there. Right? And that's the narrative that we get at the hospital right? You show up? You get a vaginal exam and then they tell you Yes, you are allowed. The doors can open for you and you're allowed to stay or like no go home because you're not far along enough for us or something right. And so that is a big shift. We will never withhold something that a woman is asking for. But we have a lot of pre conversation about what will you do with that information? And what will we do with that information. So, trying to keep our hands out of a woman's vagina actually serves them better in order to be able to trust what their body is doing and lean into that instinctual piece of labor so that they can continue on laboring? Well, knowing that, you know, we're here and supporting them, but they don't need necessarily like, they don't need a number. They don't need us telling them. Ah, yes, you call that the perfect time because look at what your cervix is doing right in this moment. Again, it's one of these major narrative shifts that happen because we think we know how birth goes simply because we've heard the stories of this is what happens in the hospital. But when we take ourselves out of that, we see that there's a whole different way to experience labor and, and birth and we get to be a part of witnessing that play out. But it is, it is hard for some women to wrap their brain around the fact that their bodies can do this thing. And all they all they have are midwives who are sitting on the chair next to them, saying nice things. Maybe right, maybe we're just quiet to have

to guess that since you're not doing vaginal exam, you have a heightened awareness to her expression, or breath or movements, do you notice that to be true that you're just paying so much more attention now, because you don't have that data that you were probably trained to have? Absolutely,

I mean, it puts us in touch with what is happening, it makes us better clinicians, because we're able to observe things that are not just data points, it's given us a lot of confidence in just being okay with supporting whatever stage that she's in. So it's really easy for the provider to have a certain expectation have a certain outcome, it's not our job to do that. It's our job to be present with what is happening, because we need to model that for the woman who is giving birth, we need to model that we are relaxed, this is normal, that it's hard work. But it's it's taking an okay amount of time that we're going to just meet each phase as it's coming. And I think one of the biggest things besides being able to just observe a normal labor pattern, I mean, like Kelly said, everything's an intervention. So any, anytime that we are Yeah, putting in an invasive procedure, like a vaginal exam, it completely takes women out of the part of their brains that they need to just surrender and give birth. And now it causes them to have to be physically defensive, even if they don't have a history of trauma, or abuse, it causes them to have to think, what does this information? What kind of judgment does this information provide about how I am personally able to labor and what I'm experiencing? And it gives everybody else a false concept of where we're at in the process? I mean, how many times can Kelly and I even say, when we did a vaginal exam, and she was two centimeters, and we had to deliver all of the bad news about how we are just in the beginning, and everyone needs to calm down. And this is going to be a really, you know, long and let's temper the expectation a little bit. And then she'd starts pushing in an hour and a half or something, right? Or vice versa. Somebody somebody is having a confusing labor pattern, and we check her and she's nine centimeters, and she doesn't finish having a baby for 12 and a half hours later, right. So like the information is not even quite that that helpful. But then we have to push that into the process and that expectation, and we can't help doing that either. So I don't even want that information. I don't want to know where she's at. I just want to be like you're doing a great job. I think your contractions are getting stronger. I'm going to set up a couple more supplies. And we'll see I mean, even Kelly and I like if we're not both at the labor, us talking about I mean reading the text thread of like, should I come Should I not come? Well, I don't know. Because she's you know, she's working really hard, but maybe she's just getting a little bit more tired. Okay, things are definitely picking up. Oh, actually, no, she's sleeping. Oh, I think I heard a little grunt at that contraction. You have to be here if she's starting to push already come right now. Hi, I'm sorry. Yeah, I think I called you too early. Because, um, you know, everything slowed down in the chat. I mean, the whole the whole thing of like, what to do at what point in labor and what to expect none of that matters to the woman's, you or your babies inside of you or it's outside of you and everything in between. It doesn't matter what what your midwives think or what you think you're capable of, or with the people around you. You know, it just doesn't actually matter. They just need to be there and present with a woman and her experience.

I personally think that, you know, the attend attentive attention to a woman's behavior is far more predictive than her cervical dilation. We were just we were just discussing the ACOG guidelines today about cervical rate, progression and the Freedman curve and how exciting it is that now the Freedman curve has been thrown out. And they've given women twice as long to, you know, go through labor, but still how ridiculous it is. Right, it's like, there is no rate of dilation that a woman has to achieve it is whatever her body is going to do. And our observation of how she's behaving is such a better gauge of where we are and what needs to happen. And it isn't even always writing it doesn't even matter. But if she's drinking a cup of coffee, you know, you know, you're not calling the second midwife if she's grunting on the toilet, you know, it doesn't matter what her cervix is, you know that the time to call? Right? Yes, you only can gain that knowledge from watching over and over and over again, not from getting in there and measuring and documenting and charting, and analyzing and making pervs.

And that's such a that's such a thing that is missed in with most providers, because they're don't, they're not in a system in which they can watch physiological birth simply play out if nothing happens, because policies, procedures, the way that people are trained in things. I mean, even midwives, the way that I was trained in certain things is way more hands on than I wanted to be right. And so learning that and understanding that and kind of untangling from that was a was a journey in and of itself. And so, yes, I think that it is really hard to pull back away from that idea of what we need data, that's what's gonna keep us all really safe, right, that's what's going to keep baby keep mom from pushing right before she's fully dilated. That's a big issue that we see come up a lot on social media and on our like, even people will email us and be like, I just I heard you say this thing. And I don't really understand because how do you know, right? Or how is it okay? Or what happens if you've

never seen someone completely lacerate their cervix and almost bleed to death? So that must be why you practice that way.

And so we're completely blowing people's minds by saying, Oh, no, actually what your body is doing is trustworthy. And so when we see women, I don't, I can't tell you how many times clients of ours have started pushing before their cervix was fully dilated, because we don't know. Oh, right. And so we can trust though that even if it's not this perfect dilation pattern, that the sensations that her body is telling her are purposeful, right? So whether that maybe she's pushing for a little bit longer, She's moving her baby down or moving her baby's position or something with some of this exertion. And and it's not necessarily dilating the rest of her cervix in that moment, right. And so there's, there's definitely some pieces to pull apart there that, I think is kind of just mind blowing to people, because that's simply not how we have seen birth play out, or how we are told to keep it as safe as possible. Can

you guys give us some examples of when you might do a vaginal exam, when you would think that it would be necessary other than a woman asking for it?

Yeah, so um, sometimes when a laborer pattern has not changed for from the observable perspective, in many, many hours, like maybe half a day or so. And we're starting to see signs that the mom herself is might not have the stamina in order to finish out the work if we're perceiving that she is stuck, or there's some kind of dystocia? Or yeah, she's just kind of frozen into the pattern. And for that to go on for many, many hours, we would have already addressed are there too many people here? Do you feel watched? Are you nourished? Do you have enough? Right? Like we would go through all of the things that we know, sometimes can interrupt that pattern, but if I have a strong sense, and maybe this has only happened twice, ever, that I think that there's a stamina issue and that by not intervening now with some more information about how exactly we can support the next process that we're setting her up for? Having having having trouble finishing the labor? Well, then I might suggest it as an option. Ultimately, you know, barring an emergency there, there's really no reason I tried to give that as an option with many other options. We could Do Evangelia exam, here's what that information would tell us, we could continue to do this thing we could we could just treat your labor as being potentially stalls. And then what will we do with that information? We will? Well, let's pretend we don't have that exact information, let's just move forward with what we observe. But some other other things that would indicate a vaginal exam, the example that Kelly gave with pushing, if a mom is pushing for a very long time, and we see absolutely no progress, and we have she's changed positions. She's, you know, expressing her discomfort or her own curiosity about like, why isn't this this changing? Then that would be a reason to offer one so that we can see exactly what's happening in there, get more information about that. A vaginal exam is indicated anytime that we have a lot of questions about the safety of the baby. So with a lot of decelerations in the heart rate, I want to know, is this something that we can overcome? Because the baby's coming quickly? Or is this something where we need to make a different decision? Because if you're six centimeters, and your baby's having these kinds of D cells, this is not a safe place for you to have your baby anymore? Those are all some reasons for for vaginal exams. Do you have do you have other ones in mind?

Yeah, I mean, you mentioned women asking for them. And again, we don't withhold whatsoever. But at the same time, it's often met with like, Okay, what, what do you want to do with that information? And that sort of conversation? And many times, it's mostly just women who are getting so close to the end who are like, this is so intense, and I just want to know, like, am I? Am I almost there? Am I almost done? And usually, through a conversation, they realize, oh, actually, I can sense in my own body that I'm almost done. And I just need to like tunnel vision and work my way. Stop

stalling is always a good tactic. Because usually, usually, if you delay it by a few more contractions, you know, you're let's just give it let's just give it four or five more contractions or so or let's do this, try this first. And then by the time we get through that next thing they don't, they're not even asking for it anymore. They're on to the next phase. Yes,

absolutely. And I'm thinking of one birth, in particular of a first time mom, who, you know, she'd been laboring for a while and felt like she wasn't making any progress. That was her own assumption. And she really was asking, like, hey, I really do want to get checked. And that conversation kind of happened on and off for a couple hours. And so we were like, Yeah, let's, let's check this out. And I was like, but first, what I want you to do is just go to the bathroom, sit on the toilet for a little bit, make sure that your bladder is nice and empty, knowing right that she's gonna sit on that toilet for longer than a contract, right? She's just gonna get in that zone of what happens when women in labor sit on the toilet, right? She came out, not even questioning if she needed an exam or not. And she's walking out waddling out with so much pressure and everything changing, right. And so even though it wasn't, I wasn't necessarily giving her what she was requesting. After the fact, she was like, I am so thankful that I get to say, now that I did this thing, and really leaned into what my body was actually doing. Rather than questioning everything.

I always liken it to, as I do this, with everything to having sex. It's like if you're having sex, and you're like, on the path to orgasm, you don't want to stop and be like, how close am I like? Can you find this? Can you better because as soon as someone says, Oh, you're close, you're 80% There's gonna be like, and we're in another state now and everything, you know. So it's, it's another bodily process that is more closely aligned with sex than anything else we do. It's the same organs, the same hormones, the same body parts. It's so funny to compare it to sex all the time. But it is so logical, it works exactly the same way where the brain is by far the most sexual organ, and it's the most important birthing Oregon, and we can really get discouraged. But with what I just said, Do you ever need to confirm a woman is 10 before pushing like, is that? Is that necessary? There's such a tone around that. Let's just make sure you're really 10 Now that you're pushing your comment about what you do there, and why you don't have to check in those moments necessarily.

Yeah, I think that I don't want to say that there's anything wrong with it necessarily. Because I understand the protective mechanism of it. I understand that the provider is trying to preserve the tissue. And so I don't want to say that that's necessarily wrong. It's wrong. If the woman says I do not want that and the provider says, This is what's happening. This is a part of working with me. You must do this next thing in order to To respond to the next phase of labor, that is wrong. But I can say, just from our own experience, we have adopted the policy of not making it a policy at all, not even making a suggestion. And we have never come across a complication that we are like, Oh, from now on, we're definitely checking every single cervix. And I want to believe that even if we did have a complication that we would come back to a reasonable response to. Setting that experience aside, and going back to informing women of here's the pros of a vaginal exam, here are the cons of a vaginal exam, it's not our go to if you ask us to do what we will. And if we think it's medically important or necessary, then we'll voice that concern, too. So a lot of times some women who have birthed in a hospital before birth with a provider who that was just a part of the next step. They really just want the milestone, they really just want that, yes, it's okay that I start to do this next thing. And that has some value in it for sure. But what has more value in it is us redirecting them to the experience that they're having in their own body. What are the positive signs that you are ready for this next thing, we don't have to rush that if you don't feel a strong urge, you don't need to start pushing right now. If you feel an urge, but you are not sure if your cervix is fully dilated or open, you can trust the urge more than you can trust what your brain is trying to assimilate that experience to. And so I think no matter what it all kind of comes down to do we trust what women's bodies are doing our women's bodies wrong? Sometimes our instincts wrong sometimes, yes, absolutely. And we can walk through that. But do we need to create a policy that is informed and based on believing that women's bodies are wrong, that their sensations are wrong, that their cervix isn't going to fully open, but they're going to have the urge to be pushing their baby out that that's wrong. I think that's a really messed up way to approach supporting women in second phase of labor,

we have to remember that vaginal exams come from the management of non physiologic birth, they come from hospital birth, where women are not giving birth, generally, not even physiologically because it's really hard to even have a physiologic birth in the hospital. But oftentimes, they're medicated. They're certainly not having an undisturbed birth, they're having a birth with intervention. And therefore all those cervical exams are are part of their process of how they manage birth, is it time to give the epidural is it time to start the Pitocin? Is it time to switch from intermittent monitoring to continuous monitoring, whatever it is, they use all that data to manage a birth and we're talking about birth in a completely different environment where we're not in the business of managing it, we're not your charting isn't necessary in the way it is in the hospital because of policies and protocols and management and all that stuff. But also, you said when if a woman starts pushing, and we don't know where she is in her labor process we observe. And if things don't seem to be progressing the way we would expect, if somebody's 10 centimeters, and they're pushing, we're going to expect to see a change in her behavior, we're going to expect to start to see the baby coming out. And if we're not seeing that, then maybe we examine because every now and then a woman is six centimeters and gets yours to push. And she could be pushing for two hours like that and have a swollen cervix as a result of it. You know, those things do happen. But that's exactly where you're attentive observation of her throughout labor gives you the information to determine the next step.

Yeah, and I think even just being willing to say, like, we're just going to watch. And then we can go from there. We can always add a vaginal exam in, but we can never take that experience back. So we want to use these skills and this assessment tool in particular, thoughtfully, because this matters in any other part of your life, who puts their fingers inside of your vagina really does matter. And so we can't just say, Oh, well, it's birth. So it doesn't like all the rules are out. It's still your body. It's still your experience. It's still your own space to be able to say like, either I don't want that or I don't need that. And we don't want to be a part of a system that confuses women that hurts women that makes them believe something that's just not true.

Yeah, I think in that is a really important piece that we can offer women from the midwifery model of care is everything we do. Everything we offer everything that we share in our expertise in this situation comes back around to the woman being in charge, being in charge of her birth, being in charge of the setting, being in charge of how she participates with her care provider and being in charge of her own body because no matter how much experience I have, no matter how equipped I am, no matter how much training I have as your midwife, I'm still not the best decision maker the woman is the best decision maker for what happens in her body and with her baby and midwives. Their job is to respond.

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We've had a lot of other midwives reach out to us and be like can we schedule a consultation just like talk through some things because I'm I'm sorting through my own stuff starting a practice that kind of stuff. And that that's exciting, too, because we need more midwives and we need more midwives who get it? Like work correct. But like who get it? Yeah, I had a lot just like you guys said I had I had to undo so much of what I learned so much of what I learned and I'm still doing I'm still going through that I'm still learning how to undo a lot of what I have learned in midwifery school because I I was absolutely trained under the medical model. Yeah. And it seemed like great it's at the time it seemed great like I'm a midwife, and I'm so women and yet I'm gonna measure your cervix every two hours and labor and documents your progress and have my hands in your vagina while you push so you know how to do it. That was what I was taught.