The Frontier Nursing Service is celebrating 80 years of service to families. At the same time, the Frontier School is celebrating 65 years of graduating nurse-midwives and family nurse practitioners, and our recent full accreditation as a graduate school. One of the events that will be held to celebrate these important milestones will be a grand reception to be held on June 13, 2005 from 7:30 to 9:30PM at the Renaissance Mayflower Hotel in Washington, DC All students, alumni, faculty and preceptors are invited to attend.

FNS to Give Two New Awards at the Celebration in Washington, DC

Attention students, faculty, alumni and preceptors! The Frontier Nursing Service Foundation will be offering two awards at the reception on June 13, 2005. These awards are designed to honor the achievements of FSMFN Alumni and FSMFN preceptors. Honorees will receive both a plaque and an honorarium.

The FSMFN Alumni Award will be given to a FSMFN alumni to honor outstanding achievements in the field of nurse-midwifery or family nursing. Candidates may nominate themselves or be nominated by other practitioners, alumni, students or faculty. Requirements are that the person is nominated by submission of an essay describing the person’s achievements and emailing the nomination to Shelley.Aldridge@midwives.org by May 27, 2005. The essay should be a minimum of 500 words. Letters of support from other individuals will strengthen the nomination. The person or their designee (another practitioner or student) must be present at the June 13, 2005 reception at the Mayflower Renaissance Hotel from 7-9PM to receive the award.

The FSMFN Preceptor Award will be given to honor accomplishments in clinical teaching of FSMFN students. Candidates may nominate themselves or be nominated by other practitioners, alumni, students or faculty. Requirements are that the person is nominated by submission of an essay describing the person’s achievements and emailing the nomination to Shelley.Aldridge@midwives.org by May 27, 2005. The essay should be a minimum of 500 words. Letters of support from other individuals will strengthen the nomination. The person or their designee (another practitioner or student) must be present at the June 13, 2005 reception at the Mayflower Renaissance Hotel from 7-9PM to receive the award.

want to strongly encourage everyone to either nominate eligible candidates or themselves for these awards. This is a great opportunity to both reward and showcase the accomplishments of our alumni and preceptors.

Available soon on a screen near you……. A short video has been produced by Frontier School of Midwifery and Family Nursing, PC623 Women’s Health, starring Patricia Caudle, Billie Couch and our newest pelvic models. Justin Rice of the Media Team has filmed, edited, and applied the video to CD to be distributed to all students prior to Level 3. This video demonstrates the pelvic examination including the positioning of the patient, the external examination, the bimanual and pelvimetry. The procedure and technique described builds on the physical examination skills learned in PC620 Health Assessment. The number one consideration during the examination is the patient. Discussion on the video includes information about providing a full explanation of the procedure, maintaining privacy, and attention to a woman’s sensibilities. Respect for the woman is demonstrated by valuing the feedback she provides, maintaining a clean environment, and using purposeful touch. Students (future providers) are encouraged to elicit questions from the woman prior to, during and after the exam as needed. Don’t miss this one!

During the early 1970’s, the consumer and women’s movements brought attention to the significance of the emotional and psychological facets of the childbearing experience. Maternity caregivers and women themselves paid more attention to emotional satisfaction with childbirth. ‘Birth plans’ became a common term, and obtaining information about what women wanted during birth became the norm during that decade. It is assumed that childbirth is a positive experience for most women. There is emerging evidence however, that some women experience birth as traumatic life event. Swedish researchers found 5 to 7 percent of women were dissatisfied with their birth experience 2 to 4 months postpartum (Waldenstrom, Borg, Olsson & Wall 1996; Waldenstrom, Brown, McLachlan, & Forster, 2000). A recent study published in Birth, found a woman’s risk of having a negative birth experience increased with having unexpected birth intervention such as operative delivery, and induction or augmentation; social factors such as unwanted pregnancy; labor factors such as pain and lack of control; and factors that can be influenced by care providers such as insufficient time spent in addressing women’s concerns prenatally, lack of support in labor, and administration of obstetric analgesia (Waldenstrom,Hildingsson, Rubertsson & Radestad, 2004). While some women may feel they had a negative birth experience, a subset of these women have what can be termed a ‘traumatic birth experience,’ with long-term emotional and physical repercussions A woman’s perception of her birth experience as a traumatic event can influence decisions for future childbearing, and lead to challenges with taking on the mothering role (Reynolds, 1997). Midwives and NP’s provide pregnancy care within the context of a respectful therapeutic relationship. We need to be aware of the significance of a traumatic birth experience to women, and implement care practices that both prevent a traumatic birth experience, and foster healing from a prior birth experience.

Jennifer Collins, CNEP class 37, wrote a paper on traumatic birth, providing an insightful overview of the topic. Click here to read Jennifer’s paper.

Reynolds, J. (1997). Post-traumatic stress disorder after childbirth: The phenomena of traumatic birth. Canadian Medical Association Journal, 156 (6), 831-835.

Waldenstrom, U., Borg, I., Ollson, B., & Wall, S. (1996). The childbirth experience: A study of 295 new mothers. Birth, 23(3), 144-153.

Waldenstrom, U., Brown, S., McLachlan, H., & Forster, D., Brennecke, S. (2000).Does team midwifery care increase satisfaction with antenatal, intrapartum and postpartum care? Birth, 27(2), 156-167.

Waldenstrom, U., Hildingsson I. , Rubertsson, C., & Radestad, I. (2004). A negative birth experiecen: Prevalence and risk factors in a national sample. Birth, 31(1), 17-27.

Suzanne presents to the birth center for her first prenatal visit. She has transferred care from a local obstetrician’s office at 23 weeks. Her previous pregnancy ended in cesarean section after being stalled at six centimeters for several hours. Suzanne has spent 3 years researching Vaginal Birth After cesarean Section (VBAC). She answers questions guardedly in short sentences, never elaborating. During the physical she will not allow a pelvic exam. She will not discuss the reason why, just firmly states that it simply isn’t necessary and she prefers not to do it. She vows that her birth experience will not be repeated.

Melissa’s first birth over 10 years ago was in a hospital. Her water had broken and she never got into labor. Her birth center midwives had to transfer her to the hospital. The midwives did not have privileges and could not continue her care. After many hours of painfully induced labor, she received an epidural – something she had strongly hoped to avoid. The nurse refused to examine her until after she was comfortable with her epidural at which time she was found to be complete. After pushing for a short time, the doctor vacuumed her 5 lb baby over a mediolateral episiotomy. Melissa did not even realize that an episiotomy had been done and the doctor never told her why a vacuum was needed. Melissa desperately desires a birth center birth and continually experiences anxiety about going to the hospital and having a repeat experience. She has even considered having her baby at home alone if her next labor follows a similar course.

These two stories, at first read, do not seem to represent childbirth that a typical obstetric provider would deem “traumatic”. Yet if one were to speak with each woman about her first birth, she would reveal memories marked by horrific pain, feelings of powerlessness, mistreatment by unsympathetic caregivers, and fear for her life or her child’s life.

Traumatic childbirth may physically define or alter future pregnancies – this much is obvious to even the casual observer. More importantly, yet vastly ignored, is the impact such an experience can have upon a woman’s psyche, her soul, during the subsequent antepartum period. The purpose of this paper is to define traumatic childbirth both physiologically and emotionally, and help the midwife identify such clientele during the antepartum. Methods of treatment will also be explored. Much research remains to be done in this area of women’s reproductive health.

LITERATURE REVIEW

Using key words of traumatic birth, traumatic childbirth, postpartum depression, post traumatic stress disorder, and reconciling childbirth, precious few articles were found. The overwhelming majority of the literature focuses on the immediate postpartum period and how to debrief and / or counsel woman who have had a traumatic experience. Most of the studies show that some women can develop post-traumatic stress disorder after a traumatic birth experience. There are virtually no studies that have been conducted on helping women in their next pregnancy to overcome or cope with a previously traumatic birth. There is literature on helping survivors of sexual abuse and/or rape during the antepartum and intrapartum period. Perhaps these techniques can be of some use to the antepartum woman to prepare for her next birth experience, but this has not been studied.

DEFINING TRAUMATIC BIRTH

So exactly what defines a traumatic birth? One author explains it as childbirth which involves actual or threatened serious injury or death to the mother or baby (Beck, 2004). The mother responds to these events with intense fear, helplessness, loss of control, or horror. Beck continues that what a mother perceives as birth trauma may be viewed as routine in the eyes of the obstetric provider, and therefore the staff may provide no interventions to relieve the mother’s stress in the postpartum period.

Parker (2004) defines traumatic birth strictly in terms of the medical interventions used – namely emergent cesarean section, forceps or vacuum assisted deliveries, fetal death or injury, or maternal injury or illness. Parker does, however, concede that a woman’s perception of the trauma may be of more import than the actual interventions. Factors associated with traumatic birth perceptions include long labors, severe pain, obstetrical interventions, powerlessness, lack of communication and support by caregivers, and differences between expectations of labor and the actual event (Beck, 2004).

Posttraumatic stress disorder (PTSD) was defined and added to the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980. Childbirth was added to the DSM-IV in 1994 as a recognized cause of PTSD (McKenzie-McHarg, 2004). One author asserts that since PTSD can occur after birth, this variant should be called “traumatic birth experience” (Reynolds, 1997).

Reynolds continues that PTSD was first described among men returning from the Vietnam War and is characterized by several features. The first is that the person has experienced a traumatic event during which she felt threatened by death or serious injury and responded with fear, helplessness, or horror. All other components of PTSD involve the ongoing reactions of the woman to the event (Beck, 2004). She will persistently re-live the event, avoid stimuli associated with the event, be emotionally numbed to the event, and display symptoms of increased physical arousal (Creedy, Shochet, and Horsfall, 2000). Symptoms persist for more than one month and affect her ability to function (Reynolds, 1997).

DSM-IV specifies that chronic PTSD cannot possibly be diagnosed less than 3 months after the traumatic event (McKenzie-McHarg, 2004). McKenzie-McHarg explains that during and after the event, - dual memories occur and it takes time for a woman to process and reconcile those 2 memories. Those who cannot, develop PTSD. According to Beck (2004), immediate single-episode postpartum counseling can be detrimental; it interrupts this reconciliation process that a woman must go through.

The incidence of PTSD in American women is 13 per 1000 vs. 5 per 1000 for men (Reynolds, 1997), though it has not been determined how much of this is due to childbirth. Reynolds analyzed other studies and concludes that the incidence due to childbirth is likely to be 0.2%. McKenzie-McHarg’s article cites that 8.1% of women in the antenatal period fulfill requirements of PTSD while only 2.8% and 1.5% at 6 weeks and 6 months respectively do. Perhaps this can be interpreted to mean that the postpartum incidence is strictly due to a traumatic birth, while antenatal it could be from a previous birth or other trauma. Beck found that 3% of women in the postpartum period exhibited intrusions, avoidance, and hyper arousal of PTSD.

Visiting postpartum depression, it is recognized that a traumatic experience is one predictor of postpartum depression. The incidence ranges from 10-24% and usually resolves spontaneously by six months (Parker, 2004). Though birth experience alone is not the sole cause of all cases of PPD, it is a component that may affect women in the next antenatal period.

Whether or not a woman is diagnosed with PTSD, it is quite probable that a woman can continue to experience physical and emotional symptoms well into the next antenatal period. The midwife needs to have some way to identify these women and help them during the antepartum. Though there are no studies available on treatments specifically for the pregnant woman who has experienced traumatic birth causing depression or PTSD, the methods described in this paper are typical of midwifery care. A woman who believes her previous birth was traumatic, whether from a physical or emotional standpoint, may in fact seek the midwifery model of care in an attempt to prevent a repeat of her previous experience.

IDENTIFYING WOMEN WITH TRAUMATIC BIRTHS

How is a midwife to know that a woman has had a previous traumatic birth experience? In Gamble and Creedy (2004), only one model (by Kendall-Tackett and Kaufman-Kantor) has attempted to explain emotional distress after birth. This model is based upon a model of childhood sexual abuse survivors. The model does not assume trauma is caused by one event, and further that interpersonal factors are central to the trauma rather than the trauma itself. This would seem to support authors Beck and Reynolds who assert that it is the woman’s perception of the trauma rather than the actual physical experience that is the core of the psychological reactions.

Begin the initial prenatal visit with a careful history of the client’s previous pregnancies including births, abortions, miscarriages, and stillbirths (Reynolds, 1997). Previous pregnancy losses may also be viewed as traumatic, and these “failures” may make her certain she will fail at birth as well. Let her tell her story and listen between the lines.

Is her memory of the birth punctuated with anger, fear, sadness, or powerlessness? Or perhaps she can remember nothing of the birth - suggestive of traumatic amnesia (Reynolds, 1997). She may describe the birth in terms of watching it happen to someone else, as if she were not there at all. This is a form of depersonalization, common in victims of trauma (Reynolds, 1997).

A physically traumatic birth may result in feelings of helplessness, horror, pain, and fear. Yet a woman who describes a typical medically normal birth can still be left feeling psychologically traumatized. Early in the postpartum period, women rationalize obstetric intervention and may not immediately express dissatisfaction with their care (Creedy, Shochet, and Horsfall, 2000). It is after time elapses and memories assimilate that dissatisfaction may emerge.

The severe emotional effects of traumatic birth can lead to trouble in the postpartum period. Inquire about breastfeeding, bonding, sexuality, and timing of the current pregnancy (Reynolds, 1997). Feelings of low self-worth or failure are commonly expressed. Postpartum depression can be a factor that extends into the current pregnancy.

Avoidance behavior is common with previous traumatic birth. She may have delayed or attempted to avoid another pregnancy altogether. Some have chosen termination vs. re-traumatization during another birth. Demanding cesarean section is avoidance behavior (Reynolds, 1997).

If she is describing what seems to be a traumatic experience, then be sure to ask if she felt that her life or the baby’s life were threatened. Refusing pelvic exams, screaming uncontrollably, or severely withdrawing are symptoms displayed by women undergoing traumatic birth (Reynolds, 1997).

The midwife should ask about flashbacks, nightmares, intrusive thoughts, or insomnia. Re-living the trauma is a manifestation of PTSD. A woman who cannot seem to trust her caregivers, asks multiple questions, or has an elaborate birth plan has a strong need to control her next experience and may suffer from extreme anxiety (Reynolds, 1997). Seeking extreme control may be the woman’s attempt to have a “redemptive” birth (Reynolds, 1997).

Find out if there was a postpartum depression and ascertain if this is ongoing in the current pregnancy. The caregiver must act if depression is suspected. Depression in the postpartum period begins after the first few weeks and can seriously affect women and their families well into the next antenatal period.

One of the characteristics of midwifery care is attending to the emotional component of her pregnancy. Midwives tend to view the whole woman – she is more than her uterus. Simply showing an interest in how she is feeling about her next labor and birth may be enough for her to begin the emotional healing necessary to reconcile her previous birth experience.

The key is listening to what the woman desires for her next birth experience. Good education is key here to helping the woman adequately prepare. For example, a woman who comes in demanding a cesarean in order to avoid labor needs to understand that cesarean birth is not pain or risk free. In fact, in Creedy, Shochet, and Horsfall’s 2000 study, 2 of 38 women who had chosen elective cesarean birth developed PTSD. A woman who has been educated during the antepartum period as to the risks, benefits, and alternatives to elective cesarean and who has done appropriate emotion work regarding her fear may choose not to have cesarean birth after all.

In Reynolds’ article as well as Parker’s, it is suggested that is imperative that a woman with a previously traumatic birth be offered excellent pain control and good communication (Parker, 2004; Reynolds, 1997). However, according to Creedy, Shochet, and Horsfall, 21 of 28 women who had PTSD had epidural anesthesia, considered the ultimate in labor pain-relief. Women must be educated that labor can never be guaranteed to be pain-free. Some pain even with epidural anesthesia is to be expected. Preparing for pain and learning techniques to cope with pain is a goal of antepartum education. While pain free labor should never be promised, good communication between caregiver and client should be an expectation. Interestingly, some women will seek a caregiver who does not promote epidurals. Perhaps part of these women’s trauma is the numbing effect of the epidural not only on the pain but also on the ability of the woman to have any control of her position or the cascade of interventions that typically coincide with epidural use.

Part of antenatal education should involve building trust between woman and midwife. Women’s experience of limited choice and control in decision-making is associated with dissatisfaction, feelings of lack of respect, and reports of more painful response to procedures (Creedy, Shochet, and Horsfall, 2000). Building a trusting relationship with a woman helps to empower that woman. An empowered and knowledgeable woman entering the labor ward, with the support of her midwife, makes more informed decisions about obstetric interventions or refusal of such. She may feel that she “owns” that decision rather than having things simply done to her during the vulnerable period of labor and delivery. Frank discussions of obstetric interventions may lessen a woman’s fear of these should the need arise during labor (Creedy, Shochet, and Horsfall, 2000).

A woman with obsessive anxiety or worry about her upcoming birth needs the support of her midwife. England and Horowitz (1998) state that worry is the work of pregnancy. All mothers-to-be have some anxiety regarding the birth. Assurance that this is normal is useful to decrease concern. The three most common worries of laboring women are: fear of pain, fear of dying, and fear of having an abnormal or dead baby (England and Horowitz, 1998).

What is more helpful is to worry effectively. A woman with anxiety should be encouraged to write down her fears, especially the ones that create a physical sensation of tension in her body (England and Horowitz, 1998). According to Birthing from Within (1998), the midwife can then go over each fear with the woman and discuss them in light of each of the following:

What would you do if this worry/fear actually happened?

What do you imagine your partner (or birth attendant) would do / say?

What would it mean about you (as a mother) if this happened?

How have you faced crises in the past?

What, if anything, can you do to prepare for, or even prevent, what you are worrying about? What’s keeping you from doing it?

If there’s nothing you can do to prevent it, how would you like to handle the situation?

For a woman with continuing fear of being “out of control” in labor, this is perhaps another interesting tool to use in the antepartum - nutritional counseling. Learning to listen to the body’s appetite helps a woman to learn patterns of behavior that can be beneficial in labor. England and Horowitz (1998) prescribe that women need to eat in awareness. In other words, practice eating appropriate foods every day and being in the moment instead of eating distractedly. This helps a woman develop patterns of being present and strong which can carry over to her pattern of behavior in labor. Nutrition is something she can do every single day to affect the outcome of her baby’s health. It is not just a mindless task. Nutrition is another way to empower a woman. Or through attention to nutrition and eating, she can learn to be present in the moment, which can be a useful strategy for coping with labor.

Exploring birth art or journaling may be a way for a woman to delve into her feelings, worries, or needs during her pregnancy and birth. As England and Horowitz state, learning what is necessary for a woman to participate completely in birth comes from within herself. Making birth art or journaling can be surprisingly revealing. It may help to unleash emotions that can inhibit a woman from letting go during labor. Having a copy of the book in a lending library for antepartum clients is yet another tool in a midwife’s bag of tricks to offer women with high anxiety about a previous birth experience.

A woman with hyper arousal symptoms of PTSD may present a very detailed birth plan to her midwife. Vigilantly planning for a better birth experience seems like a good idea – to spell out precisely what a woman wants, needs, and desires. The need for such detail stems usually from mistrust or anxiety about one’s caregivers, fear or the unknown, and/or lack of confidence in their ability to express and assert their needs in that vulnerable period of labor.

Birth cannot always be planned and it is essential that a midwife encourage women to develop an understanding of the unpredictable nature of her birth course, as well as a trust in their own bodies to give birth. A written birth plan cannot substitute for a trusted relationship between midwife and woman. If a midwife accepts a birth plan, there is a tendency for the woman to stop effectively worrying, exploring, or accessing personal resources (England and Horowitz, 1998). Writing a birth plan may initially make a woman feel powerful. The downside is that it is hard to “let go” when her guard is up in labor.

A wise midwife, Sandra Williamson, once told me that ‘what a woman resists, persists’ (personal communication, August, 2004). Avoiding a discussion of fears may cause them to persist; monsters live in the dark.

There’s a difference between normal, fleeting worries of pregnancy and what England and Horowitz call “tigers.” A tiger, real or imagined, is something that creates a physical sensation in your gut, triggers nightmares, or constant worry. Taming tigers is a task for the antepartum woman with a previous traumatic birth. A woman with tigers will not feel safe in birth because she is experiencing flight or fight. To track and tame tigers England and Horowitz (1998, p. 118) suggest that a woman:

Write down all the things she hopes will not happen

Look the tigers in the eye (let imagination flow into the fear)

Ask herself – what do I need to do to tame or escape each tiger (i.e., what will make this birth place safe?)

DO IT! (Even if she is afraid). Get help if needed.

A woman with a previously traumatic birth may need more help than a midwife has to offer. If she is truly seems to suffering from PTSD or from depression, psychotherapy may become necessary. Referral to a specialist in PTSD or postpartum depression may become essential at some point during this pregnancy.

Other women may benefit from such alternative therapies as acupuncture. Healing emotionally through acupuncture is a prime benefit of Chinese medicine (Melissa Veaudry-Martin, personal communication, October, 2004). It is thought that energy flows through the body along meridians. When energy flow is interrupted this can cause any number of physical and psychological ailments. PTSD, depression, and anxiety can be treated with the help of an acupuncturist.

Be aware, and wary, of the childbirth education classes a woman is attending. All childbirth preparation classes are not created equally. A woman with excessive anxiety may well benefit from courses taught by instructors who value normalcy and support alternatives. Courses which focus on helping a woman let go during labor and empower her to make informed decisions would clearly be helpful. Classes focusing on relaxation techniques, role-playing, partner-support, and communication skills may empower a woman and set her upon a healing path.

CONCLUSION

The incidence of PTSD and depression attributable to a traumatic birth experience is truly unknown. A fascinating finding from Creedy, Shochet, and Horsfall’s study is that 1 in 3 women reported a stressful birth event with three or more trauma symptoms (extreme pain, fear for her or the baby’s life, and a perceived lack of care). Though at the conclusion of this study only 5.6% of women actually fit the criteria for PTSD, it is astounding that so many women would consider themselves traumatized. Trauma is truly in the eyes of the beholder (Beck, 2004).

Being able to reconcile that experience is something that takes time, weeks to even years. A woman must process the experience and can learn and grow from it. Perhaps some of the methods described in this paper will be helpful to those women who have been unable to reconcile their experience thus far. Much remains to be studied in this area.

REFERENCES

Beck, C.T. (2004). Birth trauma: in the eye of the beholder. Nursing Research, 53 (1), 28- 35.

Creedy, D.K., Shochet, I. M., & Horsfall, J. (2000). Childbirth and the development of acute trauma symptoms: incidence and contributing factors. Birth 27 (2), 104 -111.

England , P. & Horowitz, R. (1998). Birthing from within: an extra-ordinary guide to childbirth preparation. Albuquerque , NM : Partera Press.

Gamble, J., & Creedy, D. (2004). Content and processes of postpartum counseling after a distressing birth experience: a review. Birth, 31 (3), 213-217).

McKenzie-McHarg, K. (2004). Traumatic birth: understanding predictors, triggers, and counseling process is essential to treatment. Birth, 31 (3), 219 – 220).

Parker, J. (2004). Does traumatic birth increase the risk of postnatal depression? British Journal of Community Nursing, 9 (2), 74 – 79.

Reynolds, J.L. (1997). Post-traumatic stress disorder after childbirth: the phenomenon of traumatic birth. Canadian Medical Association Journal, 156 (6).

Hi there, my name is Al the fetus, previously known as the ‘allograft’. Although I live within my mother’s womb, I have my own genetic makeup and immune system. Amazingly, my mommy’s body has developed a way to not only spare me from rejection but also protect me while I timeshare inside her wonderful belly.

Although I express antigens in which mommy’s body recognizes as ‘different’, my mommy and I have many special tricks that protect me from her immune system, the first being my fetal membranes. The chorion, I like to call it my ‘blankee’, is resistant to maternal rejection and protects me from her antibodies and immune cells, despite the fact that her blood bathes my blankee and is in close contact with my tissues with non-maternal antigens. Sometimes during implantation, rogue trophoblast cells may enter ma’s blood stream. These trophoblast cells do not express MHC and HLA I and II and therefore are not recognized by mama’s T lymphocytes or anti-HLA antibodies and are not rejected. Phew, lucky me! However, I do have cytotrophoblast cells that express a unique class 1 antigen, HLA-G. This fantastic antigen mediates recognition and protects my cytotrophoblast from destruction by mama’s NK cells and cytotoxic T lymphocytes.

Mommy’s body does recognize my antigens during pregnancy though. In fact, an immune reaction by her towards my paternal histocompatibility antigen, “daddy’s contribution”, is essential for a healthy pregnancy. The recognition of my antigens stimulates her body to produce blocking antibodies. These blocking antibodies mask the antigen sites and prevent her cells from binding to my antigens. In fact, a weak immune response from mommy’s body can result in harm to me. The more mom and dad are different, the stronger the response, the better the likelihood that I survive. Incest is an example where the parents are genetically similar therefore creating a weak immune response in mom which results in the lack of blocking antibodies formed , and ultimately a higher rate of fetal rejection.

Another way I protect myself is that I inhibit mommy’s lymphocytes from prolific replication. This unfortunately renders mama more susceptible to viral infections but protects me from an aggressive immune response from her. Due to this suppressed immune response, mama is susceptible infections. For example, infections of the genital tract by “Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis cause a large but undetermined fraction of miscarriages, and about 40 % of premature births” (Kanellopoulos-Langevin et al., 2003).

My buddy, the placenta, is also very important. It has high levels of progesterone, corticosteroids and hCG which all act a as immunosuppressants. The endometium also has many macrophages and secretes IgE which play a very important role in immunosuppression and rapid non-specific anti-inflammatory activity. Large granular leukocytes (U-LGL) produce cytokines which are important in immunosuppression and growth regulation. IgA is also secreted by the cells of the fallopian tubes protecting the uterine environment. (Coad, J., 2003).

Ultimately, rejection of me by mom’s body is a rare event due to the intricate system we have worked out. In fact, it is more likely that abortion happens more often due to infection and inflammation of the placenta (Kanellopoulos-Langevin et al., 2003).

Reference

Coad, J. (2001). Anatomy and physiology for midwives. Edinburgh: Mosby.

anellopoulos-Langevin, C., Catucheteux, S., Verbeke, P., and Ojcius, D. (2003). Tolerance of the Fetus by the Maternal Immune System: Role of Inflammatory Mediators at the Feto-Maternal Inerface. Reproductive Biology and Endocrinology, 1:121. Retrieved from http://www.rbej.com/content/1/1/121 on April 27, 2005.

This set of Preceptor Pearls comes from Cindy Stewart CNM, Barbe Howe CNM, and Mary Kay Miller CNM who work for Lee OB/GYN Associates in Ft. Myers, Florida.

Pearls of Wisdom

• “Birth is a normal process…it is not an illness!!”
• “It is not about us…it is all about them!”
• “Present education, provide options, and listen to them”…
• “Listen to women!”

April 11, 2005

Perkiomenville. PA

I spent six days of the first week of April in Alaska. I have been in Alaska three times before, but I think I enjoyed this trip the most. My first trip was to Juneau to consult for Margaret Crawford, Maternal and Child Health Consultant for the Department of Health. Margaret was a British nurse-midwife who took her refresher program at Booth before going to Alaska. She eventually married a captain of one of the ships that make the run from Seattle to Juneau to Anchorage and they retired returned to England to open a small nursing home. She wrote “Kitty, I’m still doing midwifery but at the other end of the spectrum.” (One of the advantages of being a NURSE-midwife.)

I’m digressing but I like to put things into the context of time. Margaret called me while I was recovering from my accident in 1980 and though I was still on crutches, insisted that I come to Alaska since “we’re not interested in your legs, Kitty, we need your voice up here to settle some things.” Therefore, I rationalized that some people, who spent their whole life on crutches, manage such excursions and I set out for Juneau. Kathy Carr, now President of ACNM, graciously met me in Seattle with a wheel chair and I spent the night in her lovely home before embarking on the last leg of the trip. In Juneau, I stayed with Margaret on Douglas Island in a bedroom with the overwhelming view of the glaciers forming the backdrop for Juneau across the bay. I could understand why those rascals with gold fever carved out the first settlement in Juneau but wondered why people stayed to occupy that little strip of land between the glaciers and the sea, accessible only by air and boat, and why on earth they made it the capital of the state. However, there it was, complete with a small hospital and Alaska’s first birth center. There I first learned that Alaskans are some of the most hospitable people on earth.

My second trip to Anchorage was to consult with the first birth center in that city, owned and operated by Georgiana Beckwirth. There, in Georgiana’s home for dinner, I met Mary Mallison, Editor of the American Journal of Nursing who later wrote that stunning “Gate Crashers” editorial on the National Birth Center Study in the February 1990 issue of the AJN. She said, “…Nurse-midwives are the nursing profession’s wedge into the system of gatekeeping that has, so far, been almost entirely physician controlled. This study of a whole different system of care can crash some gates. Use it.”

My third trip was to the ACNM Annual meeting where Sue Stone rented a car and drove some of us down the coast for dinner and shopping.

This trip was an invitation to speak at the Fifth Annual Women’s Health Break-up Seminar of the Alaska Chapter of the American College of Nurse-Midwives. The “Break-up” refers to the breaking up of the ice in the streams and rivers of Alaska. The visit started the next day with a testimony at a hearing of the legislature on a bill to include reimbursement by Medicaid for the birth center facility fee. This was followed by a well attended case day arranged by Mary Beth Gardner, FSMFN RCC (cl 11), from way up north in Fairbanks, held at the birth center owned by Barbara Norton, CNM (EPA) and her partner Karin Braun, CNM (Baystate). It was a busy day for student Trina Strand. Not only was she observed by her RCC for her 39 th labor and birth but also she presented a case for discussion. Both presentations by Trina and Anna Kent (cl 36) were exceptionally well done.

The following day I spoke at the conference on the Birth Center VBAC Study in the morning and the Business of Midwifery in the afternoon. The other sessions included marvelous presentations by Dr George Gilson (OB/GYN) on “Perineal Integrity, Trauma”; by Dr. Bradley Cruz (Radiologist) on “Female Pelvic Floor Disorders”; by Dr. Darryl McClendon (Gastroenterologist) on Colon Cancer Screening & GI Disorders in Pregnancy”; and by Shannon Wadsworth from Abused Women in Crisis Center on “Domestic Violence”. This meeting was impressive and as well organized and attended as any chapter meeting of the ACNM.

The day following the conference, I visited the birth centers operated by Direct Entry Midwives. One, owned by Tora Gerick and Angelio Davis was in Anchorage in a storefront. They took off from Zelda Collett-Paul’s (cl 02) when she closed joined the midwifery service at the Native Hospital. The other was about an hour out of Anchorage in Wasilla – a very busy, large (for a birth center) and lovely facility operated by Judy Davidson and Pam Weaver. I was impressed with their accomplishments and their passion for developing an alternative model of care for women. Licensed Midwives have founded a number of centers in Alaska. Most also do home birth. They participate in NACC and seek accreditation from the Commission for Accreditation of Birth Centers in the development of their centers. Some of the centers are staffed by LM and CNMs. Alaska, along with Florida, seems to be on the cutting edge of bringing the divergent paths to midwifery together in a complementary and collaborative fashion. There is much yet to be done but this visit gave me hope for the future. That evening I dined with Barbara Norton and her husband Dr. Bradley Cruz who is a gourmet chef. I do not know how so many midwives get these gourmet chefs for husbands. Al’s idea of a gourmet dinner is a frozen Lean Cuisine.

On Sunday evening, we gathered for a potluck supper and talk about where we are going in midwifery. There is a lot of progress in Alaska but also, as always, some areas of concern. It was great to see some of the old time CNEPers on this trip like Martha Linden (cl 02) in private practice, Cindy Bonney (cl-01)) in private practice, Zelda Collette-Paule (cl 02) former owner of one of the first birth centers and now at the Native Hospital.

When Barbara Norton dropped me off at my hotel, she handed me a check for a very large gift for the NACC Foundation from Barbara and her husband. I am still in awe of their generosity to NACC and of the marvelous hospitality/vacation that all the midwives gave me.

On Monday I was gifted a roundtrip airfare down to Homer by Mary Lou Kelsey CNM ( Utah). Homer is the furthest land point on the Pacific side of the United States. In this quaint coastal frontier town, I visited the hundreds of eagles that gather there for their winter holiday – quite at treat. Mary Lou gave me a royal tour of the town, the hospital, her practice site with her husband and his group of family physicians, and then a gathering at her home for lunch with the midwives on the Kenai Peninsula including Graduates of the FSMFN and a retired graduate of the Maternity Center Association.

Tuesday I headed home with a basketful of memories of this very special trip. I hope you enjoyed reading about it. I shall think about the splendid work our graduates and their colleagues are doing in Alaska for a long time.

I am thrilled to announce that Elissa Miller, CNM, PhD has taken the position of FNS Director of Midwifery. Elissa is a 1997 graduate of CNEP and has worked as FSMFN Course Coordinator since 2001. She has practiced midwifery in private practice in Searcy, Arkansas since 1998. She has served as faculty at several schools of nursing over the past 30 years including Arkansas State University, Harding University School of Nursing and Memphis State University School of Nursing. She has also served as Nurse Clinician for a rape crisis program. Elissa has very strong clinical skills, teaching skills and organizational skills. She loves caring for women. In February she, and her husband LeRoy, relocated to Hyden, KY from Searcy, AR to take this position. Welcome to Hyden Elissa and Leroy!

Dr Julie Marfell , Dr Mary Nichols and Dr Michael Carter all attended the NONPF conference in Chicago, April 14-17, 2005.  Dr Carter is a member of our Board of Governors and is heading the committee that is working on the competences for the professional nursing doctorate.  There was much discussion related to this issue at the meeting related to implementation of the AACN recommendations that advance practice nursing programs move towards a professional doctorate instead of a MSN as the entry to advanced practice by 2015.

Dr Julie Marfell and Kathy Wheeler attended a AANP regional leadership meeting in Asheville, North Carolina April 1-2, 2005.  The meeting was attended by other advance practice nursing leaders from the region which includes North and South Carolina, Tennessee and Kentucky.  An all day workshop on media training was held on Friday and the business meeting was held Saturday.  Jan Towers, head of the Health Policies Committee at AANP spoke Saturday concerning national legislative issues.  The annual meeting is an opportunity to network and share current legislative issues related to advance practice nursing for the region.

Students on the verge of their clinical experience write how they feel about finally reaching this point in their educational program.

2/16/05 Katie McNeff

What it means to be going to Level IV

The journey was started several years ago….as a seed thought.

Today it means I move into a new life and way to help.

It means clinical, preceptors, papers, course work.

It means moving with my higher self in a more refined way when I doubt or fear.

It means thankfulness that I was steered to Frontier.

And it means a saddle up and see where my sturdy pony takes me.

I hope it does not mean losing friends.

Losing the old is OK, but friends…no!

It means new music, sights, sounds, and smells.

2/16/05 Rachel Jones

What Level IV means to me.

Great and fantastic! I made it through Level I. Starting Level II was a huge milestone.

Level II was especially hard. I struggled. It’s kind of like giving birth.

Level I was early labor. It was exciting knowing that I had finally begun.

Level II was labor! It was harder. I got discouraged. I wanted to give up.

Level III was my typical transition. It went quickly. I had to breath and refocus. I learned new skills. The cervix is ow gone. I am complete and pushing into Level IV!

I love pushing. It feels good, and yet at the same time it is very scary. Something could go wrong. Am I going to push effectively? Will I have a shoulder dysotcia? I know everything will turn out. So many women (and men) have done this befor me, and survived. I will too!

I will be a midwife!

The Frontier School received an award from the Hyden Chamber of Commerce for Excellence in Higher Education.

As we celebrate the first anniversary of Rowan’s birth, I reflect back to something I heard you, Jeannie, say last Christmas. You gazed adoringly at your little silken-haired son in your arms, and told him, “You have been the desire of my heart for ever so long.” I know, from having accompanied you on your journey toward Rowan’s birth, that he is indeed the fulfillment of your soul’s longing. The whole story of Rowan’s coming-to-being is the story of your love, and the intensity of love that surrounded him and all of your family as he came to join us all here on earth. From the circle of love between you and Dane, to the expansion of that circle as Malena entered into it, to the further expansion that Rowan brought , and into the greater circle of family and community love that supported you, Rowan’s birth story is a love story.

On a cold, snowy January night, 13 women gathered in the quiet warmth of Sandy and Stan’s yurt. We brought with us stories, small gifts, symbols of nature’s bounty, symbols of God’s love, symbols of our love. One by one we shared these with you. You lay there amongst the boughs, open, vulnerable, receiving of our tears, hopes and prayers for new life within you. Your serenity spoke of acceptance of the emptiness caused by baby Francis’ loss, yet, your whole being spoke also of desire for this new child of your longing. We did not yet know of little Rowan’s presence there in our midst that night. Yet, he was there, with love cascading around him and over and through his mother’s body, poured out from her and for her by those of us there. Thus was Rowan nurtured by love from his earliest moments.

What delight you took in your pregnancy with Rowan! Such celebration over the early, bittersweet morning sickness! How proudly Malena shared the news that (for a brief while J) was just a momentous secret that you and Dane shared! And the community celebrated with you. Nor can we forget MaryLou’s ecstasy at being the Nani of yet another beloved grandchild. This child that was prayed into being was being joyously celebrated by all.

You ripened, Jeannie, getting large with child. Radiant, cumbersome, miraculous, tired. Each moment of this longed-for pregnancy was savored. And, oh, how you looked forward to the incredible power of the soon-to-be labor. You hungrily awaited the bringing forth of new life, of embarking once again upon the unspeakable beauty of the birth journey such as you and Dane experienced with Malena’s birth.

But it was not to be as you had imagined. Rowan, for reasons that only he and God knew, chose to follow his uncle John’s path of breech entry into this world. And for many long hours, your world, Jeannie, came crashing down. You wept heartbroken tears, sobbing at the loss of all that you hoped to give your loved ones. You wept for not being able to bring Rowan into this world through your own power, into a peaceful room surrounded by loving family and friends. You wept for not being able to give Dane the intimate experience of working with and supporting you as together you brought forth your new family member. You wept for not being able to show for Malena the strength and beauty of women giving birth. Your heart broke, and first Dane, then Sheryl, then myself, could only offer our shoulders to cry on, our arms to embrace you, and our love to surround you.

Yet, knowing that you had a C-section in front of you the next morning, you bravely let go of your dreams and faced the reality in front of you. The tumult subsided, although your grief did not, and you thought about what pieces of your dream you could bring into the operating room with you. Dane, obviously, would be there to share his love and this birth with you, and to welcome his child into the world. You could bring the serenity of your birth music, which you had so carefully chosen, to set the tone of peace in the operating room, that your child might be born into music and song. You would bring your birth items – your little blue prayer shawl that Wendy gave you in your loss of Francis, and that you fingered daily in memory of that little one and in anticipation of your newborn babe. You could bring your photograph of beloved Malena, so that her presence would be felt at this birth. Rowan’s placenta, which had nourished him so lavishly, and connected your life source to his, would be welcomed into my purple and blue ceramic birth bowl, a gift to me from Sheryl, a gift come full circle. I was honored to be asked to be part of this birth experience.

Thus, you faced Rowan’s birthday, with great anticipation of his arrival and of finally holding him in your arms and at your breast, but also with grief for the lost birth experience, of turning your most precious gift to your child –that of giving him life, giving him birth-over to the power of others. I still felt from you the heavy emptiness that follows a night of tears and mourning. Yet, as we drove through the misty winter morning along the fog-shrouded Columbia, it seemed as if you slowly left the weight behind. Strengthened by Dane’s quiet presence, you mustered the courage and grace needed to go deep inside, to find your own and Rowan’s spirit, that the three of you might make this journey together in love.

The preparations for surgery must have seemed distant and cold, so far removed from the birth you had envisioned. Instead of finding your own power, it was piece by piece being removed from you. Yet, as the mother-womb embracing your child, yours was the only world he would know until the moment of birth. This was something that only you could give him, the warmth, security, peace and serenity of your embracing presence. You dedicated yourself to removing fear, tension, grief or any negative emotion from his inner world, the nest of your womb. Deeper and deeper inward you turned, till all of the hubbub of preparation faded from your world, and all was calm in that deep place where you and your precious babe resided.

Rowan entered the world into a space that can only be described as sacred, a term not often used to describe an operating room. The room was permeated by prayer, whispers, music and utmost respect for the arrival of a new life. The touch was human, healing, not sterile or mechanical. You and Dane brought forth new life, as Sheryl and Dr. Hansen midwifed Rowan into this world. He arrived pink and robust, announcing his arrival with a lusty cry. He was only at the warmer long enough to be well dried, then he was wrapped and Dane brought him to your side. From then on, he was calm, quiet, wide-eyed, drinking in the sight of his parents, and you, your child. Rowan was born.

Neither you nor I were there when Dane brought this precious bundle to his big sister. That was so hard for you to miss, this meeting of your two precious children, a loss of something that can never be replicated. Yet, true to the reality of all parenthood, a part of your heart went with your children, and knew intimately every gasp of delight from Malena, every wide-eyed taking-in of his sister’s face from Rowan, and every proud grin of Papa watching over it all.
In the recovery room, neither you nor Rowan missed a beat in initiating the intimate dance of breastfeeding. Your little barracuda knew just what he wanted to do, and how to do it; your wounded soul healed with every suckle he took. Sheryl looked on like a proud grandma. Soon you were settled into your own room, with Rowan nestled at the breast. A proud and gentle Papa breathed a well-deserved sigh of contentment. Malena happily created artwork for her baby brother, and Sharman and I just beamed. Nani soon arrived, and marveled as I placed her grandson in her arms. The sun rose higher in the Brewster sky, melting away the mantle of fog. A new day had begun, heralded by the borning cry of this very dearly beloved child. A child born into a special, sacred place of love and peace; a child born of the shared love and strength of his parents; a child whose birth enabled his big sister to indeed witness the courage and beauty of her mother bringing forth new life. Indeed, a miracle fulfilled.

My telling of this love story is my gift to you, Jeannie and Dane. However, I hope that as Rowan grows older, and you share this with him, he will re-awaken to the knowledge of all of the great love that beckoned and welcomed him into this world, all the while rejoicing in his being.

March 29, 2005

Dearest Kitty. 

I just returned home from a long night on call - and wanted to share with you, that you were on my mind.  I spent the night caring for a young couple having their first baby - a baby girl who came into this world a little after 5 am (following a 3 hour second stage).  I'm not sure why, but for some reason, I found myself singing (in my mind) "Its in Every One of Us" as this young mother began to push.  Maybe it was because she had arrived to the unit 30 hours after her membranes had ruptured - she waited until her contractions had started because she knew if she arrived any earlier we would start that cascade of interventions that she desperately wanted to avoid.  SHE knew she could give birth naturally.  Maybe it was because I was blessed to have my favorite consulting doc on call - one who also knew that this woman had the capacity to give birth naturally and didn't force unwanted (and unnecessary) intervention.  And maybe it was because she started pushing at 2:30 am and I was wearily searching for ways to stay alert.  Whatever the reason, as the song started playing over and over in my head - your image popped in there as well, and I began to replay the wonderful stories I have heard from you over the years.  And among the stories, I came to a couple of conclusions that I wanted to share with you (3 hours in a dark and quiet room, except for the glimmer of light shed upon her perineum and the faint grunting sounds she made, offers one a very long time for reflection).  So.....I decided to write and share these with you - because I really think you need to hear them.  Both of these are conclusions I have drawn as a result of the work that we did together on the article published in the 50 th Anniversary Edition of the JMWH First, I think you are entirely too humble when it comes to recognizing the contribution you made to midwifery when it comes to what you did to get this school up and running - and I want to thank you for those contributions.  Having said that, the second conclusion I came to is that I have no idea where I might be or what I might be doing had it not been for your vision and your drive to bring that vision to fruition.  Maybe I would still be a frustrated labor and delivery nurse - taking out my hostility on undeserving OB residents - or maybe I would have left maternal child nursing all together and gone back to arranging flowers.  At any rate, I want to say thanks to you - from me (and over 1,000 nurse midwives) - who are in practice today because a leader in midwifery, in Perkiomenville PA, knew that there is a better way to deliver maternity care and that there were nurses out there who would attend midwifery school if they didn't have to relocate for school.  And thanks for the stories too - they'll stay with us forever. 

Fondly,

Kathryn

Frank came to work at the Frontier Nursing Service in 2000 as a part-time employee working after school to assist us with our computer systems. After graduation, Frank went to Spencerian College in Lexington earning an Associate Degree in 2003. Upon graduation from college, Frank joined the FNS as a full-time employee. He is currently enrolled in Canyon College pursuing a Bachelor’s Degree in Computer Technology.

Under Frank’s guidance, FSMFN has been able to take a quantum leap into the future with all of our communication systems. He has set up computer networks which connect our school, the Mary Breckinridge Hospital, the FNS rural health clinics and our administrative office in Lexington so that we are able to communicate with each other seamlessly. Even though we are all separated by miles, we “talk” to each other through our computers as if we were all together in one building. He has refurbished all of our work stations with the most up to date equipment and he assures that everything is functional every day.

As a person, Frank is wonderful to work with. He is very patient as he explains to us what we need to do to learn any new skill. He is always thinking about the future and how to improve the working conditions of our employees and our students. He is intelligent, polite, and always willing to help in any way. He has worked countless hours to assure that all our systems are in place and that we have what we need to accomplish our goals. He never leaves with out saying, “If you need anything else, just let me know.”

Currently Frank is mentoring two students from Leslie County School during the after school hours. He is also a Leslie County volunteer fire fighter. He is a solid member of the Leslie County community and we are very proud to be able to work with him every day. He is very deserving of the honor of Employee of the Year.

Our very own Francie Likis, FSMFN Alumni and current faculty member was featured in the Spring 2005 edition of The Fountain, the news bulletin of the Graduate School at The University of North Carolina at Chapel Hill. I am betting that not all of you know that Francie is currently a doctoral student at UNC. She received the much coveted and respected Royster Fellowship and is in her second year of studies.

Service to women’s health is the core value that motivates Royster Fellow Francie Likis every day of her career as a midwife. Whether its delivering babies, conducting research about contraception or teaching her skills to other students, Likis wants to know that she has contributed something at the end of the day.

 Likis, a doctoral student in Maternal and Child Health, is one of the many women at Carolina who have dedicated their careers to serving the health needs of other women. This dedication is part of what makes the University’s health care graduate programs some of the nation’s best.

 “I view my entire career as one of service,” says Likis. “I have had the privilege of serving both patients and students.”

 As a midwife, she provides a unique service to women looking for alternatives to traditional care. “our care is holistic and education intensive,” she says. “Midwives provide gynecologic care for women throughout their lifetimes, not just during pregnancy and birth.”

 The Fountain Spring 2005.

 Congratulations on your achievements Francie. We are so proud of you.