Turning Pain into Power

Jennifer Donaghue
July 13, 2012

GW’s Midwifery Services offers women the chance of a natural, unmedicated birth.

Friday, July 13, 2012

By Jennifer Eder

The birth of Jennifer Donaghue’s first daughter in January 2010 did not go as planned.

She hoped for an empowering natural birth, but Ms. Donaghue ended up with an emergency Cesarean section. She missed out on getting to hold her daughter, Juliana, in the first few minutes of her life since she was strapped to a table in the operating room. She struggled to start breastfeeding, and the recovery from surgery was difficult.

So a year-and-a-half later when Ms. Donaghue got pregnant again at age 35, she wanted a second chance at a vaginal delivery. But because she had already had a C-section, she knew that many obstetricians wouldn’t offer the opportunity because of the increased risk of uterine rupture.

That’s why Ms. Donaghue contacted the Midwifery Services at George Washington University Medical Faculty Associates (MFA), a group of four midwives who guide women – including those who have already had a C-section – through the natural and unmedicated process of childbirth.

The Midwifery Services opened its practice at MFA in June of 2010, but these certified nurse midwives have been practicing in the Washington area for years. One of the reasons GW’s practice is unique is its model of collaborative care with obstetricians and labor and delivery nurses. While more than 96.5 percent of GW’s Midwifery Services patients deliver vaginally (and of those who deliver vaginally, 86 percent do so without an epidural), the midwives are able to call on GW Hospital’s obstetric, anesthesia and neonatal services when medical intervention is required.

With a waiting list of up to 20 women per month, the practice has rapidly been gaining popularity amongst Washington-area expecting mothers who are attracted to a more holistic, natural approach to childbirth.

“Women are seeking empowerment. They want to trust their bodies and do something women have been doing since the beginning of time,” said Whitney Pinger, director of midwifery services at GW.

To meet the increased demand, GW will be adding two additional midwives to its practice this summer and expanding its case load from 30 to 45 women per month this fall.

But the practice is not for everyone. Women are required to exercise regularly, hire a doula -- someone who serves as a birth coach and provides support before, during and after labor – and follow a strict diet that includes no processed foods or refined sugar.

For Ms. Donaghue, this meant practicing some very different habits than she did during her first pregnancy.

“My doctor during my first pregnancy never talked about the importance of nutrition, so I just ate whatever I wanted,” said Ms. Donaghue, whose first child was 9 pounds, 2 ounces.

The idea behind what the midwives call “optimal nutrition for pregnancy” is to double a woman’s blood volume; grow a healthy placenta, umbilical cord and amniotic fluid; and most importantly grow a baby that is an appropriate size for a woman’s pelvis. All of these goals increase a woman’s chances of a vaginal birth. The midwives also have their pregnant moms drink red raspberry tea, which is believed to help strengthen the uterine and pelvic muscles, and take evening primrose oil supplements to soften the cervix.

“You cannot expect a healthy labor and delivery unless you’ve had healthy nutrition,” said Ms. Pinger during a “Meet the Midwives” event earlier this year, where expecting and hopeful mothers gathered to learn about GW’s practice and the benefits of midwifery.

Central to GW’s practice are what Ms. Pinger calls the “Midwifery Pearls for Normal Birth,” which maximize a woman’s chance to have a natural labor. They include waiting for labor to start on its own rather than inducing it, eating and drinking during labor and encouraging women to move around – whether that’s walking, squatting or crouching on hands and knees – rather than lying down in a bed.

“When our women are laboring, they are working hard. It’s like they’re running a race,” said Ms. Pinger, who said the need to have strength and endurance during labor is another reason the practice requires its moms to exercise aerobically 30 to 60 minutes per day during pregnancy.

A Holistic Approach

Midwifery care advocates for non-intervention in the absence of complication. For their non-risk patients, the midwives don’t use continuous electronic fetal monitoring. Instead, they intermittently listen to the heart rate. Epidurals, which Ms. Pinger said have been found to slow labor and result in lower rates of spontaneous vaginal birth, are avoided. Instead, women are provided continuous labor support from both a doula and a midwife, and tactics such as back massages, warm showers and laboring in a hydrotherapy tub are used to ease the pain.

“They tend to rely less on equipment and more on their own hands and intuition. They are infinitely patient and supportive. You never feel rushed with them, and most important of all, they treat you as a whole person – spiritually, emotionally and physically,” said Mariah Sixkiller, who had a successful vaginal delivery with the midwives in February, delivering her son, Samuel, naturally after having a C-section with her first child

While these methods are not the norm for laboring mothers across the U.S., GW’s midwife practice has excellent outcomes.

In the U.S., the number of C-sections has doubled in the past 15 years. Today, nearly one in three babies born in the U.S. is delivered via a C-section. At GW’s midwife practice, fewer than 5 percent of women have a C-section. For women like Ms. Donaghue who are seeking a vaginal birth after a C-section (known as a VBAC), the national success rate is between 60 and 80 percent. With GW’s midwives, it’s 93 percent.

Committed to a more holistic approach than traditional medicine, the midwives offer women comprehensive services including nutrition and lifestyle coaching, primary care and will continue to provide gynecology care after pregnancy. During check-ups throughout the pregnancy, patients rotate between all four midwives so that a relationship is formed with each one.

On an early spring day in March it was Ms. Donaghue’s turn to see Nora Fisher, one of the practice’s four midwives. The chemistry between the two women seemed more like old friends than doctor-patient. Ms. Fisher greeted Ms. Donaghue with a big hug and a warm smile. Throughout the visit, the women shared laughs as Ms. Fisher measured Ms. Donaghue’s belly and used her hands to feel the position of her baby.

“I’m a very big touch person,” said Ms. Fisher. “I believe the human touch is calming and healing, and I really listen to my patients.”

The midwives believe it’s important for their patients, especially those attempting a VBAC, to actively visualize a vaginal delivery.

“VBAC encompasses psychological challenges because you think physically you can’t do it, and having to overcome your doubt is very important,” said Ms. Pinger.

To help overcome that challenge, Ms. Donaghue, a senior international student and scholar advisor in GW’s International Services Office, listened to daily affirmations that her body was designed to deliver a baby and she would have the strength to do it.

Mitigating the Pain

Thirty-three-year-old Rebecca Good sought out GW’s midwifery practice in the hopes she could have a vaginal delivery with her second child. She knew if she had another C-section, she would never have the opportunity for a vaginal delivery.

While midwives and some OB-GYN physicians will let women try for a vaginal delivery after they’ve had one C-section, most won’t let women try after two C-sections. The risks are viewed as too high.

So Ms. Good began working with the midwives to prepare for a vaginal delivery.

“I didn’t want to have a C-section again if it wasn’t necessary so I looked for a practice that I knew would work really hard for me to have a VBAC,” said Ms. Good, who works as a chaplain at Johns Hopkins University’s School of Advanced International Studies in D.C.

She stopped eating sweets. She made a commitment to swimming and walking. And she hired a doula to provide extra support during the birth.

“Labor is really intense, and a doula can help make you as comfortable as possible and use creative ideas to mitigate the pain,” said Ms. Good.

In the Washington area, doulas may cost from $600 to $1,500, depending on how many visits they offer before and after birth, whether they come to the house at the beginning of labor and how long they stay after delivery.

Ms. Good and her husband, Josh, chose a $650 package that included one pre-natal visit, meeting the couple at the hospital, staying two hours after delivery for breastfeeding support and one post-natal visit. Their doula, Michelle Peterson, who had assisted in 55 births, said in addition to providing physical support during labor, she gives emotional support to both the expecting mother and her partner.

“I reassure them that what they’re feeling is normal, especially when they get to the home stretch,” said Ms. Peterson. “Everyone comes to a point where they question if they can really do it. They feel like it’s so unbearable and don’t know if they can keep going.”

When Ms. Good went into labor around 4 a.m. at her home on Capitol Hill, she immediately texted Ms. Peterson and called the midwife on call to let them know it was time. After arriving at the hospital, Ms. Peterson massaged Ms. Good’s back with a tennis ball, coached her through the painful contractions and offered her ginger ale and apple juice.

When the contractions intensified, Ms. Good began to doubt she could endure them without an epidural. Ms. Peterson and Ms. Pinger wanted to avoid an epidural in order to give Ms. Good the best chance of having a successful VBAC. So they helped Ms. Good into one of GW’s hydrotherapy tubs once she was eight centimeters dilated – the warm water helps decrease the pain.

“You have to get them into a position where they can get over the hill, and they’ll ultimately be really happy,” said Ms. Peterson.

A week before Ms. Good showed up in labor at GW Hospital, Ms. Donaghue was attempting her VBAC alongside her husband, Peter, and her doula, Jennifer Thorson. To help progress the labor, Ms. Thorson had Ms. Donaghue walk the halls of the hospital for hours – pausing and grasping the railing during each contraction.

“It hurt like hell, and there’s definitely a point where you lose motivation,” said Ms. Donaghue. “Thank God for my doula and my midwife.”

Ultimately, both women were able to find the strength to keep pushing. They had prepared for this for more than nine months. They had eaten right, exercised and mentally told themselves they would be able to do this. And they had a team of people committed to helping them have the birth they wanted.

“Witnessing this transformation of pain into power is really amazing,” said Ms. Fisher.

After nine months of hard work and hours of even harder labor, both Ms. Good and Ms. Donaghue had successful vaginal deliveries and welcomed two healthy babies into the world: Claire Elyse Aleta Good and Elena Mae Donaghue.

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