The Canadian Postpartum Midwife Way

I soon knew my favorite part of my job as a midwife in Canada was after the baby was born. That is when the hard work begins, when most of the support is needed for mothers. This is when I believe my job as a postpartum midwife was that to fill the community support void. Coming to see women in a scheduled way in the postpartum and not waiting until a problem arises to visit. Having a neutral trained professional visiting women in the postpartum helps them feel informed and emotionally supported. Gives new mothers or returning mothers reassurance that they are doing well with the work of being a mother, that their baby is well. Not having to leave the comfort of your home for the first weeks of your babies life for weigh- in’s and well baby checks. I loved watching women’s confidence build with each visit or if not helping them set goals to overcome challenges and not giving up.

If I am able to ease some of the uncertainty in the postpartum that women experience then I am happy. It fills my bucket to help women overcome what ever challenges arise after their baby is born.

Even though I left my profession as a Midwife behind in Canada and no longer catch babies, I do not feel less fulfilled because I still get to be with women during their pregnancy, birth and postpartum here in Israel. I get to share the Canadian Postpartum Midwife way with my clients in Israel, share with them this beautiful model of care.

Perineum Support at the time of Birth

I have been thinking about perineal support a lot lately, yes these are the things that run through my brain. I have a close connection with the varying levels of perineal pain that my clients experience in the postpartum. I see time and time again how much more pain women experience if they were given an episiotomy as apposed to natural tearing or an intact perineum. I am proud to say that in my 7 year career as a midwife I only performed 3 episiotomies, all of which were due to emergencies and every time with the consent of my client.

When interviewing new clients, I will ask them of their fears or concerns about birth. Many women voice being afraid of episiotomies. I validate these fears, no one wants to be cut on the perineum at birth. Perineal tissue for the most part is able to stretch and if it does need to tear it will take a gentle route, much more gentle then the scissors choose.

I write this blog with a slightly heavy heart, because I would like to say that Israel is forward thinking that there are not many episiotomies being done here and that a woman’s consent is always taken.

“Ensuring that women are involved in the decision-making process in the event that an episiotomy might be needed is also critical. Performing an episiotomy—or any other intervention—without a woman’s informed consent is a violation of her right to respectful maternity care. Addressing the non-evidence-based use of episiotomy is key to improving maternal health and women’s birthing experiences worldwide.” For further information please visit this link

Non-evidence based use of episiotomy is still very common unfortunately. I understand that episiotomies can be a life saving procedures at times, if used within an evidence based way. “Research has shown that natural tears typically are less severe (although this is perhaps not surprising since an episiotomy is designed for when natural tearing will cause significant risk or trauma). Slow delivery of the head in between contractions will result in the least perineal damage. “ For further information please visit this link

Of course when I am in an Israeli birth room with my client in the capacity of their Doula, I will never interfere with their doctor or midwife needing to do an episiotomy in a true emergency. What I will do is to try to prevent them in situations where there is not an emergency. I will advocate for my client to have a chance to birth her baby without being cut. I celebrate those moments for my clients when an episiotomy is prevented and their perineum stretches beautifully or if it did tear it only was minimal and healed easily. It brings me joy when the women I support are able to recover in the postpartum a little more easily with less perineal pain. Some may call me a anti-episiotomy vigilante, so be it, if I can help promote trust in women’s bodies to birth their babies then I will take that title for the cause of no more unnecessary episiotomies.

I wish for all women freedom of movement for their vaginal birth, that they can choose the position that is comfortable to them and not because it is convenient to their practitioner. That they are given warm compresses, and oil is used and that their perineum is supported in a way that promotes an intacted perineum. That there is a trust and communication between them and their care provider to slow down the birth of the head of the baby. That women feel safe to birth with dignity, power and that their voice is always heard through consent.

Breastfeeding on Day 3 to 5 Postpartum, why are these days significant?

Your baby was born two days ago, you have survived the second night which is notoriously challenging, your babies digestive system has been gently started by receiving colostrum from your breastfeeding efforts. You may be starting to question weather you have enough milk as your baby wants to breastfeed more and more. Yes it is common that babies feed more and more at this point, they are working on transitioning your breast milk. This transition to your breast milk usually occurs on day 3 postpartum, where the breast milk increases and is no longer only colostrum milk. Women who needed a cesarean section could have a delay in their milk transitioning until day 4 or day 5 postpartum.

When your milk transitions you may experience engorgement. Engorgement is when the breast becomes very full with milk, possibly hard to the touch. Engorgement of the breast can make it difficult for your baby to latch on well to the breast, this is due to the areola (darkened skin around the nipple) becoming too full which causes the baby to latch only on the nipple tip. The baby latching only on the tip can cause pain, injury and limit babies intake. Also when the breast becomes to full (Engorged or in hebrew Godesh) it is difficult for the baby to drain the milk out of the breast. Engorgement if not managed could cause your milk supply to deplete. Why does engorgement if not managed deplete your milk? There is a hormone in the breast called FIL (Feedback Inhibitor of Lactation) FIL lowers milk production when your breast is full with milk (when FIL is more present), when the breast is emptied there is less FIL present and your body produces more milk. Enough medical lingo, basically if your breasts are full a lot of the time and they are not being emptied your milk production will decrease. This is why management of Engorgement is so essential to your breastfeeding success. Day 3 to 5 postpartum is likely the time when your breast will be their fullest, your body has given you enough breast milk for multiples and you may only have one baby to feed. The best way to manage engorgement is to have your baby empty the breast. How do you achieve that? Before breastfeeding your baby, place a hot cloth on your breast for about 5 minutes, then once warm hand express your breast into the warm cloth until the areola is soft and the baby will be able to latch onto the breast with a wide asymmetrical latch. While your baby breast feeds massage the breast to maximize the milk emptied. After your feed is done you want to place a cold compress on your breast to lower the inflammation. This cold compress could be green cabbage leaves that you have cooled in your refrigerator, a cold cloth or gel pack. It is also important to take good care of your self during these days, eat, hydrate and sleep as it is common for women to feel very emotionally vulnerable in the days that their milk is transitioning. I wish you a smooth postpartum and am happy to offer support to you.

A Parenting trick: help your newborn baby sleep longer

Early days of parenting can be overwhelming, there are so many new things to learn. New mothers can be tired from a long birth, they are beginning to navigate breastfeeding which is not a small task. Getting your newborn baby to sleep is a challenge all new parents struggle with. A big part of why I love my work is the joy I receive from helping parents after they give birth. The postpartum education, support and reassurance a woman receives after birth is invaluable. Even myself, a midwife who had helped hundreds of women navigate life with their newborn, needed the support of her midwives in the postpartum. I could not have navigated all the challenges that presented themselves without their knowledge and problem solving skills. This is why I am very passionate to bring that support, knowledge and reassuring presence to each and everyone of my clients. It fills my heart to make a families transition to parenting easier, through the postnatal education I offer at every home or hospital visit. Here is a video sampling one of the many ways I make transition after birth easier.

Swaddling your newborn baby can help recreate the tight hug they experience inside the womb. It can help them not wake due to their startle reflex. Swaddling after a good feed can gently encourage baby to sleep longer, allowing you to bank on your well needed sleep. Although swaddling a baby will never replace the arms of their parent, it will likely help you and your babies sleep improve.

Spinning Babies - a new perspective on solutions to labour progress challenges:

I participated in a wonderful two-day Spinning Babies intensive workshop taught by Rachel Shapiro in Jerusalem beginning of November 2018.  During the workshop my midwife brain was thinking yes, yes, this is wonderful, it makes so much sense!  When I did my Bachelor of Health Science degree in Midwifery at Ryerson University Toronto Canada, we learned anatomy and physiology on many important levels, including the mechanisms of the birthing baby and pelvic floor anatomy.  During my education as a midwife, we discussed ideal positions in labor and birth to open the pelvis bones making it easier for baby to come through, however there was little discussion on how to make more room by also releasing soft tissue, ligaments, tendons and fascia.  Hearing this in the Spinning Babies’ workshop was like a light bulb turning on in my brain, I was very excited by its possibilities to solve my clients’ labour challenges.  I thought of so many births I had witnessed in the past that ended up in cesarean that very well could have been prevented with the knowledge I have gained with Spinning Babies. 

When you learn a new paradigm of viewing mechanisms of birth, the pelvis and soft tissue it does not become second nature overnight.  Learning a new skill takes time to build confidence and courage to implement it.  As if the universe was saying “Yes Terri you can do it, you are on the right path!” circumstances were placed in my lap that were ideal for Spinning Babies skills.  Who knows maybe these issues were always there, maybe it was that I was looking at them with different eyes, a different perspective.  Whatever it was, I decided to go with its forward momentum. I began with teaching my clients the ‘Three Sisters’.  The ‘Three Sisters’ includes the Forward leaning inversion, the Side-lying leg release, and Rebozo sifting all of which if done regularly prenatally can release ligaments, tendons, pelvic floor muscles and fascia. The Three Sisters works by making more room for baby to enter the pelvis optimally.  Then I got the opportunity to put my new found knowledge into action in labour. Toward the end of one of my Doula client’s pregnancy at 38+6 weeks gestation her waters broke with a very large gushes of water, without labour.  She moved to the hospital, to be assessed for rupture of membranes which was confirmed.  She had no signs of labor and babies head was high (-4 station).  The stop watch was set by the hospital, for multiple reasons one: being her Group B Streptococcus (GBS) status was unknown (A type of bacteria that has the potential of infecting the fetus or newborn baby, about 30% of women carry GBS at the time of birth). Another reason for the time limit was due to the protective membranes no longer present thereby allowing GBS and other bacteria’s to travel to the fetus and mother potentially causing infection.  Most women will go into labour within 24 hours of Spontaneous Rupture of Membranes (SROM) and the rest within 48 hours of SROM.  I sprung into action the first morning they were at the hospital wanting to start the three sisters with her, to help encourage her baby to enter the pelvis and ideally start labor spontaneously.  Entering her tiny hospital room shared with 3 other beds, I realized this was going to be easier said then done.  One of the Three sister maneuvers I was able to do with a little creativity was the Rebozo Sifting.  In order to do it for her I stood up on her hospital bed with the head of the bed for her to lean on and succeeded to do Rebozo Sifting without a staff member walking in to see me standing on the bed.  This is what I meant about needing courage: implement a new and effective method in an institutional clinical environment is not always easy.  Fast forward almost 2 days after pre-labour SROM where breast pump induction, homeopathic options and the Three sisters possible in such a small room were used , unfortunately without significant spontaneous contractions. 

The decision was made between the hospital and my client to start Pitocin.  At 15:00 Pitocin was started by IV and the babies head was still very high (-4 station in the pelvis) which means above the inlet of the pelvis.  There is terminology called the 3 P’s that I was educated in my Midwifery degree.  The three P’s are Passenger, Powers and Passageway.  ‘Passenger’ being the baby, ‘Powers’ being the uterine contractions, ‘Passageway’ being the pelvis and soft tissue.  In my client’s clinical situation, the ‘Powers’ were being addressed by adding Pitocin and creating contractions from the uterus.  Her body responds quickly to the Pitocin and she developed very strong contractions.  That being said the Passageway (pelvis) and Passenger (baby) were not being considered, the baby remained very high. To complicate things further she was asked to lie on her back in order for the monitor to read the contractions more easily.  Lying on her back narrowed the passage way, not allowing baby to enter the pelvis, not to mention increasing her pain level.  Spinning Babies philosophy strongly supports problem solving labor progress by looking at where the passenger is- where the baby is and how to optimize their position in the pelvis and descent through the pelvis hence the word ‘Spinning’.  Spinning meaning the babies rotation and descent through the pelvis during the different stages of birth.  Due to the fact that I had not yet been called to her labour for support and my client needed to lie on her back with strong contractions she requested an epidural for pain relief at 19:00.  I arrived at 20:00, the babies head remained high and was noted to be asynclitic (tilted to the side).  At 20:45 my client’s cervix was noted to be 9.5 cm dilated but the head was still high at -2 station and asynclitic.   At this point Mom has developed a fever and babies heart rate has become tachycardic (a heart rate above 160 beats per minute), the medical team is starting to become worried about the mother and babies well-being. We requested to do Spinning babies to help the baby to descend in the pelvis, her midwife was luckily very open to the idea.  We started side-lying leg release and within 5 minutes of doing it she begins to feel pressure.  The midwife reassesses her and the babies head has descended significantly from -2 to +1 station ( moving from above the pelvis inlet into the mid-pelvis.)  The baby did not stay descended in the pelvis (regressing to -2 to -1), we did the other side for side-lying leg release and the baby came down in the pelvis +1 and she becomes fully dilated the time was 21:30.  22:30 pushing began, doctors and midwives are in the room and still very concerned about the babies elevated heart rate and talking about cesarean if baby is not able to be brought down low enough to be assisted by vacuum.  Pushing on her back does not descend the pelvis, as in this position the sacrum is being pushed in and thereby narrowing the outlet of the pelvis.  I advocated for her to able to push on her side, side lying pushing successfully progresses the baby further down.  Eventually her baby is low enough for the doctors to assist the mother with birthing her baby, baby is born at 23:40 healthy and put skin to skin with Mom.  I truly believe after going through this experience that this labor would have ended in cesarean if it weren’t for the help of Spinning babies.  I look forward to future opportunity to use my new found knowledge, its possibilities are endless.