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WHO recommendations: non-clinical interventions to reduce unnecessary caesarean sections1

by Cathy Daub PT, CCE and CD(BWI) and Horatio Daub, MD, MPH                       

 

Just 40 years ago when I first gave birth, a cesarean was still considered an operation done only for specific life-threatening conditions as well as when having had a prior cesarean.   Today, it has become an accepted, if not almost routine, way of giving birth.  What has caused this significant and disturbing trend?  Concerns about the sustained and unprecedented world-wide rise of cesarean section has prompted the World Health Organization to issue this report.  In the “WHO Recommendations Non-clinical Interventions to Reduce Unnecessary Caesarean Sections, they stated, “This is a major public health concern. There is an urgent need for evidence-based guidance to address the trend.” Their report was based on evidence of the effectiveness of interventions from an updated Cochrane review of 29 studies.

The importance of this WHO report is that it represents the first global guidelines of a clinical encounter between a health-care provider and pregnant woman in the context of patient care. The purpose of the study is to “provide evidence-based recommendations on non-clinical interventions that are designed to reduce cesarean section rates.” Their report acknowledges that a cesarean is a surgical procedure that when necessary can prevent maternal and newborn mortality when medically indicated.  However, beyond a certain threshold at risk, may result in increased maternal and perinatal morbidity along with both short and long-term health risks that may extend for decades beyond.  This in turn results in substantial increases in health-care costs, morbidity, and mortality for mothers and babies.

In the USA, about one in three births result in a cesarean, having increased dramatically from 5% in 1970 to over 32% in 2016. Today.  it seems to matter what country you are born in and in the USA, which state you live in. In the USA it is better to be born in Utah (22.3%), Idaho (21.9%), New Mexico (24.8%),  Alaska (23%) or Hawaii (25.2%) versus Mississippi topping the list at 38.2% or Louisiana (37.5%), Florida (37.4%), West Virginia (34.9%), NJ (36.2%) or Connecticut (35.4%).

Internationally, Finland has a low cesarean rate of about 16% of births and the UK’s rate is about 24%. Brazil tops the list at more than 50% with even higher rates in private sectors.  Latin America and the Caribbean follow with high cesarean birth rates at 40.5% and North America (32.3%) ranging down to Asia (19.2%) and the lowest in Africa (7.3%).

When cesarean rates vary to this degree, it must be due in part to how birth is managed rather than birth itself. The international health-care community has considered the ideal rate for caesarean section to be between 10% and 15%.  WHO concluded that “at the (global) population level, cesarean rates above 10% were not associated with reductions in rates of maternal and newborn mortality.”

The WHO report acknowledges that although societal changes such as increases in obesity, multiple pregnancies and older pregnant women have contributed to the increased cesarean rate, these are unlikely to explain the variance  of cesarean section rates between various countries or states.  Other non-clinical factors such as women wanting to plan their birth dates, physician factors, malpractice fears, and other economic and social factors are also implicated in the high variability of cesarean rates.

We know today that there are many non-clinical interventions that have proven to be successful in labor and birth but which are underutilized by most women, birth professionals, and facilitators.  These include warm water, optimal pelvic positioning,  the presence of a birth companion or doula, massage, speaking encouraging words, and keeping a positive and private environment.   On the contrary, medical intervention rates are very high with for example a 75% rate of epidural anesthesia and other obstetrical drugs to control pain.

In the WHO report, recommendations to reduce cesarean targeted women, health care professionals, and health organizations, facilities, or systems.

For women

  • Education that addresses fear of pain, advantages and disadvantages of cesarean sections and vaginal birth, risks and benefits of pain relief techniques and obstetrical drugs, and guidelines for indications and contraindications of cesarean sections.
  • Relaxation training and stress reduction programs conducted by nurses
  • Couple-based prevention programs that are inclusive and provide problem solving suggestions, mutual support strategies, and conflict management.
  • Psycho-education for women who fear childbirth itself and that address topics such as normalization of individual reactions, stages of labor, hospital routines, birth process, and pain relief.

For Health-Care Professionals

  • Implement “evidence-based clinical practice guidelines combined with structured, mandatory second opinion for cesarean section” in settings with adequate resources and senior clinicians.
  • Implement “evidence-based clinical practice guidelines, cesarean section audits and timely feedback to health-care professionals.”

Health Organizations, Facilities or Systems

  • Establish a collaborative midwifery-obstetrician model of care where the model of staffing is based on care provided primarily by midwives with 24-hour back-up from an obstetrician who provides in-house labor and delivery coverage.
  • Establish financial strategies such equalizing physician fees for cesarean and vaginal births.

The highest level of certainty evidence was the recommendations for health-care professionals where accountability was required.  Interventions in labor and birth need to be guided by the basic premise that if the harms clearly outweigh the benefits for valued outcomes, they should not be used.

The WHO report stated that women find learning new information about birth to be empowering  but it should not provoke anxiety.  Women want emotional support alongside the communication of facts and figures about birth. But interestingly, there seemed to be no differences in cesarean rates based on computer-based decision aids, booklets, role play vs lecture for women with fear of childbirth, or educational brochures in spite of the fact that women seemed to want such things.

They did not see differences among various ways to present the childbirth information, but none of the discussed formats for learning included an experiential and emotional preparation for birth that is based on basic human values as is available in BirthWorks.

BirthWorks childbirth preparation is designed to build confidence for birth.  We offer a broader systems approach to childbirth that is based on a foundation of human values where optimal pelvic positioning is key.  Women learn how to work with their bodies in labor, knowing that the knowledge about how to give birth is already born within every woman.  Included are also identifying beliefs and releasing fears thus re-framing them to a positive experience,  the role of hormones and the value of the microbiome as well as the importance of mother-baby skin-to-skin contact, mother-daughter relationships, the value of doulas, and grieving and healing.  Classes are interactive and a place of joy and learning which is what the experience of birth can be.  BirthWorks childbirth preparation builds confidence and decreases fear through the integration of mind, body, and spirit.

Reference:

  1. World Health Organization 2018. This report is available under the Creative Commons Attribution –NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO, https://creativecommons.org/licenses/by-nc-sa/3.0/igo).
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Reflections From A Mom With Multiples

by Cristin Tighe CCE(BWI)  (and Sienna Morrow)          

Taking care of one baby is a lot of work.  New moms often say they were busy all day but don’t exactly remember what they did!  Just imagine taking care of newborn twins or triplets!  I am a BirthWorks Mentor and one of my students, Sienna Morrow, who is in the BirthWorks Postpartum Doula Program sent a response to the question below that brought me to tears as it made me remember my own experience with my twins.

Question:  When is a baby considered to be premature?  List five main concerns a new mother with multiples might have in the first few months at home and how you would address them.

She wrote:

  • A baby is considered premature if born before 37 weeks.
  • A mother with multiples might be concerned with getting adequate sleep, breastfeeding two babies (tandem), creating a routine that works for both babies, bonding with each baby, and having enough support.
  • I would encourage the mother to tune into the babies and create a routine that works for all of them together by helping her process how things go throughout the days and areas where she is struggling.
  • I would help her connect to groups of moms of multiples in her area and give her time to have conversations with her partner about how they can support one another.
  • I would address any breastfeeding concerns that she has and build up her confidence with praise and words of wisdom.
  • I would also help her explore her own resources and discover things she can do to build a support network in her current situation.”

I, myself, gave birth to my twin boys at 38 weeks and 6 days so they were not premies. I breastfed my boys 21 of 24 hours the first day, and then it was like 16 hours a day until we all learned to tandem feed. I felt stuck in my primal brain for weeks, almost like having no awareness of being human most of the time.  As I reflect back on the experience, I am laughing, remembering some of my chimpanzee robotic-like thoughts that were running through my head during that time:

  • Feed next baby, get other one, feed other….fall down and sleep…are they both safe? …zzz…wake up! Baby must eat…
  • I starving, ravenous, soooo thirsty, give me water
  • Bladder bursting, need to pee
  • Need shower, crusty, smelly, sweaty, sticky
  • Where is Annalissa? (That’s my daughter who just turned four.  This thought would come with adrenaline as I was falling asleep feeding some baby boy – not sure who it was half the time, didn’t care, trusted my husband who rotated them.

These thoughts just repeated over and over, like the film “Groundhog Day”, until around four months.  Then, I woke up, like from a dream, checked we were all alive and when we were, I sighed deeply.

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Pushing in Labor??

By Horatio Daub MD, MPH  and Cathy Daub PT, CCE and CD(BWI)

A recent study in the Journal of American Medical Association1, October 9, 2018, found that delaying pushing once full cervical dilatation is reached for 60 minutes vs. immediate pushing had no significant effect on the rate of spontaneous vaginal delivery (85.9 % in the immediate group vs. 86.5% in the delayed group). However there were significant differences in the incidence of postpartum hemorrhages (2.3% in the immediate pushing group vs. 4.0% in the delayed pushing group) and chorioamnionitis  (6.7% in the in the immediate pushing group vs. 9.1% in the delayed pushing group).

This contradicts the previously held beliefs that delayed pushing results in a better chance of having a spontaneous vaginal delivery and is safer for the mother and baby.  In fact, the study was stopped early because of lack of effect of the delayed pushing on the percentage of spontaneous vaginal births and the significantly increased morbidity from higher rates of postpartum hemorrhage and increased rates of chorioamnionitis increasing the morbidity for mothers and babies. The new recommendation to not delay pushing once full cervical dilatation is achieved is supported by the findings of this study because of the significantly decreased morbidity for mothers and babies with immediate pushing.

There are some important points to consider:

  • First, regional anesthesia would confine women in labor to beds and not allow them to walk & move their bodies thus allowing easier movement of the baby down the birth canal assisted by gravity rather than fighting it when they are confined to bed in a supine position.
  • Second, this study assumes that the experience and outcomes of birth are improved with regional anesthesia numbing them to the experience of birth. There are no studies to support this hypothesis.
  • Third, the study ignores evidence that using non-pharmacological comfort measures in place of regional anesthesia reduces cesarean sections in birthing women when they are mobile, upright and free to labor in whatever place and position, works for them.
  • Fourth, the study assumes women with partially paralyzed, desensitized abdominal muscles can effectively push a baby out of the birth canal. Birthing women are basically being set up for failure by being anesthetized and partially paralyzed and being confined to the “stranded beetle” position hindering the natural progression of labor and delivery. In addition, with regional anesthesia, both motor and sensory nerves are blocked, making it impossible for her to walk or use her legs to change her position.

But what if women learn that positioning themselves in such a way that they are working with gravity instead of against it, only bearing down slightly when their body demands it at the top of a contraction, to be a less stressful and easier way to birth their babies?  Then they don’t need as much power from their abdominal muscles and they can more gently birth their babies.  They instinctively follow the cardinal movement of their babies moving and rotating through the pelvis to be born.

Reducing unnecessary cesarean sections was the topic of the recently published “Non-clinical interventions to reduce unnecessary caesarean sections by the World Health Organization (WHO). (Read more in our upcoming November Enews).   These recommendations target women, health-care professionals, and health organizations, facilities or systems. For women it addresses what they call “Psychoeducation” where childbirth preparation can help address fear of pain and labor, and explain stages of labor, hospital routines, the birth process, and pain relief among other topics.  Their recommendations include nurse-led applied relaxation training programs, and normalization of individual reactions.

Today, too few pregnant women are receiving comprehensive childbirth preparation for their upcoming births.  In BirthWorks, we advocate birth education to be very early in pregnancy or even before pregnancy.  Our program is comprehensive and integrates the mind, body, and spirit through the practice of human values.  Working with the mind means helping women to release fears and feel safe having women choose the people & environment for her birth.  For the body, it means finding optimal pelvic positions that ease movement of the baby through the birth canal, the value of mother/baby skin-to-skin contact, the physiology of birth, and more. For the spirit, it means knowing that all women are born with the knowledge about how to give birth, believing it, and having patience.

Non-pharmacologic methods to ease labor pain and reduce cesarean section are well known but underutilized.  These include relaxing in warm water, moving in labor, keeping upright positions as much as possible, having the presence of a doula to help a woman in labor to feel safe, and having early childbirth preparation. The way to decrease cesarean sections is not to have women lying on their backs with regional anesthesia, unable to move out of bed, but rather allowing women to move and assume the positions that work for their birth.

Why not concentrate instead on ways to help pregnant women develop a new paradigm about birth- one that includes being upright, walking, having comprehensive childbirth preparation that offers both an academic and emotional preparation for birth, finding a safe place to birth, and the value of a doula.

Given the fact that most women in the USA give birth with epidural anesthesia, the researchers were trying to develop strategies to improve the percentage of spontaneous vaginal birth .  Not surprisingly, they found no improvement with pushing early or late in labor in this outcome.  They did find that immediate pushing decreased postpartum bleeding and infections.  In order to make significant decreases in cesarean section and instrumental deliveries, we believe the logical conclusion is to decrease the numbers of women who are anesthetized for their births in the first place.

We recommend that allowing women to use movement and gravity to assist their births along with other non-pharmacologic measures, is what will improve outcomes  for women and babies and decrease cesarean rates the most effectively.

  1. Sperling JD, Gossett DR. Immediate vs Delayed PushingDuring the Second Stage of Labor. JAMA. 2018 Oct 9;320(14):1439-1440. doi: 10.1001/jama.2018.12877. No abstract available. PMID:30304414
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Tips for Sleeping Through the Night During Pregnancy

 

After announcing your pregnancy, one of the first pieces of advice veteran-parents will likely give you is to “get as much sleep as you can now because once the baby comes, you’ll be missing it”.

Unfortunately, it’s not that simple. According to an study published in Sleep Medicine, women experience “short sleep duration, poor sleep quality, [and/or] insomnia” throughout all three trimesters. The study went on to find a direct correlation between sleep quality and stress, and looked at how sleep impacts pregnancy as a whole. Sleep deprivation has a significant impact on cognitive abilities, such as reaction time, alertness, general performance, and even emotion (as if pregnancy by itself doesn’t make managing emotion hard enough).

The good news is that there are a number of ways to help promote quality sleep throughout pregnancy – and even sleep through the night. It may take a little trial and error, though, as there are a number of factors that may be contributing to restless nights.

One reason for poor sleep during pregnancy is general discomfort. As your pregnancy progresses, your body shape changes, making it difficult to find a comfortable position to sleep in. If you are typically a stomach or back sleeper, you may feel particularly miserable, and even unnatural, trying to sleep on your side. To remedy this, try putting a pillow between your knees to help align your hips. You may also find some relief by putting a soft pillow under your growing belly to help support some of the weight. If you’re lacking in extra pillows around the house, there are a variety of “pregnancy pillows” designed specifically for this purpose.

As your baby (and belly) grows, there will be more and more pressure on your bladder – resulting in more and more trips to the bathroom. This is particularly frustrating after you’ve finally fallen asleep (and gets increasingly more frustrating each subsequent time after). Unfortunately, there aren’t any miracle cure-alls for this one, but you can be strategic about hydration. Try to load up on water as much as possible during the morning and mid-day, and then by the evening start to taper off your liquid intake (of course, don’t risk dehydration just to avoid that 12 am wake up).

Stress is another common reason for poor sleep quality for anyone – but even more so for pregnant women. A 2014 study examined stress hormone levels in pregnant women and found that as gestation progressed, the hormone levels increased incrementally. Pregnancy is stressful as it is, there is a lot to worry about (especially if you’re a first-time mom) so the added hormone levels only make it worse. If you’re experiencing insomnia as a result of a racing mind, try using a sleep-focused guided meditation app on your phone to help you fall asleep. Consider investing in a mouth guard if you find yourself clenching or grinding your teeth due to tension. Finally, if the stress is so bad that you still feel exhausted despite getting a full night’s rest, try implementing (appropriate) moderate physical activity, changing up your diet, or limiting your social commitments to allow you to get more rest. Always remember to consult your healthcare provider if the stress, or exhaustion, is overwhelming.

Sleep is essential to a healthy pregnancy, but don’t be too discouraged if you’re not getting as much sleep as you did before pregnancy. The best thing you can do is give yourself some grace and permission to rest during this time, even if that means saying no to a few social events or taking a midday nap to make up for those frequent overnight bathroom trips.

Sarah Johnson

sjohnson@tuck.com

Tuck is a community devoted to improving sleep hygiene, health and wellness through the creation and dissemination of comprehensive, unbiased, free web-based resources. Tuck has been featured on NBC News, NPR, Lifehacker, and Radiolab and is referenced by many colleges/universities and sleep organizations across the web.

 

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A Look at Pregnancy and Birth Trauma and Polyvagal Theory from the Perspective of Prenatal and Perinatal Psychology

by Sally Dear-Healey, CCE(BWI), CD(BWI)

Prenatal and perinatal psychology (PPP) provides a unique and critical awareness of the process of conception, pregnancy, and birth that is lacking from most childbirth education programs, doula trainings, and provider’s educations. One of the main benefits of pre- and perinatal psychology is that it recognizes the need to consider not only the mother and her experience, but also the baby and their experience.

Polyvagal Theory, developed by Stephen Porges (1994) provides us with a dynamic understanding of how and why mammals shift between a calm states that promote intimacy and optimize health, growth, connectedness and restoration to flight, flight, or freeze states, which are normal autonomic nervous system (ANS) responses to threat, fear, and lack of safety. Individuals with a history of trauma are especially vulnerable as their “neural reactions have been retuned towards a defensive bias and they (have) lost the resilience to return to a state of safety” (Porges, S.W. and Dana, D., 2018). The goal of Polyvagal Theory is to keep an individual within their “window of tolerance” in their sympathetic nervous system (SNS) (fight or flight –aggressive defense system) and parasympathetic dorsal vagal complex (DVC) (freeze – passive defense system) and focus on feelings of connection, safety, and orientation to the environment which are part of their parasympathetic ventral vagal complex (VVC), otherwise known as the social engagement system (SNS).

“An estimated 70 percent of adults in the U.S. have experienced a traumatic event at least once in their lives” (https://www.sidran.org). This estimate may be low. According to a Journal of Trauma and Stress article, “Most respondents (89.7%/N = 2,953) reported exposure to at least once DSM-5 Criterion A (trauma) event” (Kilpatrick et al., 2013). Specific to birth, a study investigating the prevalence of Post-Traumatic Stress Disorder (PTSD) following childbirth found that 17.2% of women had symptoms of PTSD following childbirth (Shaban et al, 2013). Again, these statistics may be low as PATTCh (Prevention and Treatment of Traumatic Childbirth) reports “Between 25 and 34 per cent (sic) of women report that their births were traumatic” (http://pattch.org/resource-guide/traumatic-births-and-ptsd-definition-and-statistics).

Returning to pre- and perinatal psychology, Thomas Very, M.D. and David Chamberlain, Ph.D., both pioneers in birth psychology and founders of what is now APPPAH, the Association for Prenatal and Perinatal Psychology and Health, realized “There is a growing body of empirical studies showing significant relationships between birth trauma and a number of specific difficulties; violence, criminal behavior, learning disabilities, epilepsy, hyperactivity and child, alcohol and drug abuse” (Verny, 1981). For mothers and babies birth trauma often results from birth-related difficulties including but not limited to premature and postmature births, breech births, inductions, anesthesia, forceps deliveries, and cesareans. Trauma may also result from a mother’s feeling a lack of safety and support, which is transposed directly to her baby.

This is where Polyvagal Theory provides us with a method of understanding how trauma manifests during conception, pregnancy, and birth and how we can actively create feelings of safety, thereby facilitating increased social engagement, improving bonding and attachment, and increasing the overall short- and long-term health and wellness for mothers and their babies/children.

Polyvagal Theory proposes that cues of safety are an efficient and profound antidote for trauma. According to Porges, “The theory emphasizes that safety is defined by feeling safe and not simply by the removal of threat… and is dependent on three conditions: 1) the autonomic nervous system cannot be in a state that supports defense, 2) the social engagement system needs to be activated to down regulate sympathetic activation and functionally contain the sympathetic nervous system and the dorsal vagal circuit within an optimal range (homeostasis) …; and 3) cues of safety … need to be available and detected via neuroception (2018, p. 62 & 62).

Birth is an intimate event, and according to Porges “Intimacy is a state-dependent behavior.” He goes on to say that “For mammals, immobilization is a vulnerable state” (2018, p. 63). To help women achieve the state of intimacy necessary for conscious conception, pregnancy and birth we need to work with women prior to conception and throughout their pregnancy so that they – and subsequently their babies – are able to regulate and change previously disruptive autonomic states by accessing the social engagement system and ventral vagus so they are not re-activated by previous or current trauma. The social engagement system is recruited through “cues of safety such as a quiet environment, positive and compassionate … interactions, prosodic quality (e.g., melodic intonation) of … vocalizations, and music modulated across frequency bands that overlap with vocal signals of safety… (Porges, 2018, p. 66). In other words attitudes and behaviors, what people say but how they say it, as well as their facial expressions.

The primal perspective is one of the foundations of prenatal and perinatal psychology. As David Chamberlain is often quoted as saying, “Newborn babies have been trying for centuries to convince us that they are, like the rest of us, sensing, feeling, thinking human beings.” To be clear, this research is not meant to induce guilt since parents often get caught up in the type and hype of birth practices that are prevalent at the time and even the normal pressures of life can contribute to a stressful pregnancy or lead to a traumatic birth. Instead, its purpose is to increase awareness and effect changes in policies and procedures that might otherwise cause or contribute to trauma and subsequent short- and long-term harm in mothers and their babies/children. For those that have already been affected, help is available. Play therapy, womb surrounds, craniosacral therapy, birth simulating massage and various other forms of therapy and bodywork have been found to be highly effective. For more information on prenatal and perinatal psychology and polyvagal therapy, as well as opportunities for healing and working with these individuals please go to https://birthpsychology.com.

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The Sounds of Silence During Labor

Written by Sarah Baker CCE(BWI)

I recently listened to an On Being podcast entitled “Silence and The Present of Everything.” The guest, Gordon Teppitt, was an audio ecologist, a career which I’d never heard of and found utterly fascinating. His gentle and calm voice spoke in a poetic way about his experiences and the insights gained from them, a subtle lulling lilt in his energy that soothed me.  His insights on silence, or lack thereof, spoke deeply to me. He defined silence not as an absence of sound, but an absence of noise – an important distinction that is often misunderstood.

Teppitt’s observations were a catalyst to me reflecting on my own experiences with silence. Naturally, being a birth worker, I couldn’t help but immediately think about one of the many skills I’ve had the privilege of refining as a result of my doula work: being comfortable with silence during labor, and more importantly, willingly remaining present during the silent space of labor. In that space is something sacred, something that can’t be easily quantified, and it’s something that is easily missed by those who aren’t paying attention. In all fairness, it’s not  their fault they miss out on the sacred: the interventions and energy and hustling/bustling of the hospital environment drown out the sacred sounds of silence during birth. It dulls the senses and mutes some of the most beautiful aspects of birth by putting such staunch focus on the clinical, the medical, the mechanical. Women and partners often find comfort in the sound of their baby’s heartbeat galloping away on the fetal monitor. The blips and beeps of IV and epidural pumps become white noise or aggravating interruptions. The atmosphere becomes casual and party-like as a revolving door of family members and friends visit the laboring woman. The irritating sounds of nursing station gossip blurts in every time the door is opened. All of it interrupts and disrupts the sacred silence of birth, so much so that many people often cannot distinguish the normal sounds of birth from the man-made noise so common in modern birth.

Just like Teppitt defines silence as an absence of noise rather than an absence of sound, so it is with the experience of silence during labor.  During labor, women instinctually release primal, guttural moans and groans, often referred to as “vocalizing.” When I discuss the concept of vocalizing during my BirthWorks classes, one of my go-to phrases is this: “It’s not a matter of forcing yourself to make these sounds, but rather, giving yourself permission to do so.” The sacred space of silence during labor is often not an absence of noise, for the normal sounds of labor can even be quite loud as they resonate outward from a woman’s vocal cords. But it’s the absence of modern, technological birth noises.

For some women, it takes a conscious effort to let go of their inhibitions, which result from a number of influences (society, family, her personality and temperament). Such influences can create cognitive dissonance within her body. Her instinctual, “old” brain is gradually taking over as she shifts into active labor and is creating the perfect environment internally for the delicate hormonal dance that’s necessary to achieve a healthy labor.

As she begins vocalizing, she naturally starts filling the silent spaces with sounds that may feel very foreign to her. And yet when inhibitions are present, her frontal cortex, or “new brain” is fighting for attention, sending a loop of unproductive messages:

“Listen to yourself, you sound weird!”

“What will they think of you with these crazy noises you’re making?”

“Control yourself, it’s too risky to let go of control.”

Teppitt described why people feel uneasy and uncomfortable with an absence of noise: sitting in silence leaves us feeling vulnerable. Vulnerability invites us go deeper, to allow our truest selves to be seen. Vulnerability is simulataneously exhilarating and terrifying. And so it is with labor and birth. When a woman allows herself to turn off the noise, both the “noisy chatter” of her frontal brain and the literal noise of modern birth, what’s left is an uncomfortable silence and a part of herself she’s never experienced before.

A curious phenomenon begins to occur once she becomes comfortable with the uncomfortable newness of her primal self and primal sounds. Her guttural sounds begin to fill the laboring space. The sounds wash over her with each contraction and create a palpable tension felt by every person present. In between each contraction, she sits in true silence. Time begins to stand still, not only for the woman, but for us, too. All of us become keenly aware of every subtle sound we make, keeping quiet, only speaking when absolutely necessary and in low, hushed voices.

For people present with her who are unexperienced with birth or unexperienced with the normal sounds of birth, this gentle tension created by the birth sounds and the literal silence often leads to feelings of discomfort. Tippett says, “True listening requires vulnerability.” And so it is for the people present, with no external noise to distract them and drown out the primal sounds of birth or to fill the silence in between contractions, it leaves them vulnerable.

Even as an experienced birth professional, I am not immune to such feelings of vulnerability. Over the years, I have learned to embrace this vulnerability. I have learned (and am continuing to learn) to let go of my own inhibitions, quiet the empty chatter of my own mind, and enter into this vulnerable, sacred space with her. I push through the uncomfortable and find my own strength because I know what she is doing in those sacred moments is much greater than my discomfort. I let her primal sounds wash over me, I tune into my own energy and make sure it’s in alignment with the sacred, I encourage her with simple phrases if needed, and resist the urge the fill the silence with unnecessary words. I let go and open myself up fully as she surrenders to the ebb and flow of waves and birth sounds.

Birth has changed me and continues to change me. How could I possibly be left unchanged by such sacred vulnerability, one of the most vulnerable experiences that a woman will ever face, and one in which I willingly remaining present with her? Wisdom, that has only come with experience as I’ve learned to embrace silence and the sacred sounds of birth, is truly a gift that has carried over into every other area of my life. Birth has taught me to welcome my own vulnerability, to sit with myself in the absence of noise, and to embrace the silence of my own heart.