Sunday, December 12, 2010

Don't ask, just do

How often do we give authority to other people when it rightfully belongs to us? 

My friend--the one who had a cesarean for her second baby (breech) and whose third baby was breech until a successful ECV--had her third baby several weeks ago. It was a precipitous labor, and she made it to the hospital just minutes before her baby was born. I was hoping to drive out for the birth, but when she called me in the middle of the night with contractions that were 1-2 minutes apart, I knew there was no way I'd make the 3-hour drive before her baby was born.

She told me me her story later on that day, and a few things jumped out at me. Once she made it to the birth room, the nurse said, "now let's get you on the monitor." She said, "no way!" and went to the bathroom, where her water broke with a dramatic gush . She started feeling really pushy, so she headed back into the room. The nurse said, "let's get you on the bed." She said, "no way I'm lying down!" Instead, she grabbed a Chux pad, knelt on the floor next to the bed, and pushed her baby out a few minutes later.

I was present when she had her second (breech) baby. She went into labor when the one OB who did vaginal breeches was out of town, so she knew she was heading for a cesarean. She labored for several hours at the hospital before consenting to the surgery. During that time, if she didn't want to be on the monitors, she'd simply unplug herself and march into the bathroom. When she was done laboring in the bathroom, she'd go plug herself back in, standing up and swaying next to the bed. She didn't ask permission to get off the monitors--she just did it. Because of her "I know what I'm doing; don't mess with me!" attitude, the nurses didn't bother her. 

This is the same woman who, during her first birth, gave birth kneeling. It was the first time her OB had ever seen an upright birth. My friend had tried to lie down as requested but found it impossibly painful, so she got up on her knees and stayed there. She would have preferred to give birth standing up, but knelt as a concession to the OB, who was nonplussed enough as it was with my friend's unconventional birth position.

How many times have we read stories where laboring women weren't "allowed" to get out of bed, where the nurses wouldn't "let" them get off the monitors, or where the doctor said they "had" to lie down to push and couldn't change positions? This has happened to many, many people I know both personally and through my blog.

I don't want to minimize the enormous power institutional and medical authority have over laboring women. Nor am I implying that it was a failure of the individual laboring woman when she was told she couldn't do X or Y. Not at all.

But...

What if we simply stopped asking permission? What if we simply did what we wanted to? What if the mantra of laboring women became "don't ask, just do"?

Don't ask if you can eat or drink. Just do it. Don't ask if you can get out of bed or walk around or go to the bathroom. Don't ask if you can change positions or give birth kneeling or squatting. Just do it.

Do it with confidence. Do it with an "I know what I'm doing, and please don't mess with me!" attitude.

Just do it.

Let's join Dr. Michelle Harrison's vision of a new womanly revolution, from her book A Woman in Residence:

I used to have fantasies at Doctors Hospital about women in a state of revolution. I saw them getting up out of their beds and refusing the knife, refusing to be tied down, refusing to submit – whether they are in childbirth or when they were forty and having a hysterectomy for a uterus no longer considered useful. Women’s health care will not improve until women reject the present system and begin instead to develop less destructive means of creating and maintaining a state of wellness.

34 comments:

  1. What a great post!!! Love this idea!!!

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  2. Fantastic post! Something I'll be thinking about when I have my next baby.

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  3. This is a great point, one I don't know if I've heard made before. I will be sending it to my sister, who is 12 weeks pregnant. She is choosing her providers and exploring all her options right now, and I am happy to be helping her!

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  4. I've never asked permission to do ANYTHING when in the hospital. Ever. I'll take myself off the monitors, drink, go to the bathroom, go walking,...I've never been challenged. I don't do it with an "I dare you!!" attitude, I just do it like I expect everyone to be fine with it and it works out. If you don't ask, they don't have the opportunity to say no and once the deed is done the threats of awful things happening hold little to no weight.
    The only time anyone has ever scolded me was when I disconnected and re-connected my daughter's IV once when dressing her. I did it the right way, used an alcohol swab etc...the nurse had no idea that I knew what I was doing (this was just a rehdration IV and I've taken care of my own IV's, midlies and PICC lines for years)and freaked out a bit.

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  5. Sadly this is something I didn't know to do with my first 2 births - both c-sections. I found my strength and confidence with the 3rd though and had a wonderful, empowered and empowering vba2c. "Don't ask, just do." Not just good advice, it's our right.

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  6. I am 29 weeks pregnant so reading lots of these blogs. Why is everyone so concerned about monitoring the baby during delivery? I will do anything to make sure my baby is ok, to me monitoring the baby seems like re-assurance.

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  7. This is the question that comes to my mind whenever I read about women being "forced" to have an induction and/or c-section that isn't medically indicated.

    I did this to some extent after transfering to the hospital from a planned home birth. I said no to a c-section 3 or 4 times before I consented. Turns out it was necessary, but no one knew that until the ob be got in there saw my daughter's position in the womb. I did not want to be rushed into it.

    The one thing I wish I had just done instead of asking for permission was eat. I begged for just some crackers before I got to pushing, but the hospital said no of course. If I ever have to transfer to the hospital in the future, I'm going to tell my husband to give me food regardless of what hospital policy is.

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  8. I love this and will absolutely be following this when I have my baby! As they say, it's much easier to ask forgiveness than permission!

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  9. @ Anon 7:33: we're concerned not about ANY monitoring of the baby, but a specific kind - continuous monitoring - ie when they wrap that band around your waist. Women are concerned about it for two main reasons: 1) it provides nurses an excuse to force you to remain in bed, where laboring often becomes unbearable painful because you can't move; and 2) there is NO medical evidence to suggest that this kind of monitoring is safer for your baby. Nurses can monitor via a doppler (the little hand held thing your doc/midwife uses during prenatal visits to check heart rate). That's JUST AS SAFE. The external monitors are glichey and have been proven to overreact to problems that aren't problems. This means that the monitor goes off suggesting there's a problem with the baby's heart rate. But that might not actually be true, and you might find yourself being rushed into a cesecearan section that's unnecessary. (These points are all evidence-based, not the opinions of the posters here. You can find some research on this.)

    Anyway, Rixa, I LOVE this post and I agree in so many ways. But here in the States there *are* women who are threatened with Child Protective Services for refusing some maternity care, including bed rest, inductions, and C-sections. There is that well-known case in Illinois where a home birthing mother had her newborn taken away from her just for having a home birth (when she had to transfer for shoulder dystocia). Women are sometimes forcibly restrained during unwanted interventions. I'm not suggesting that we allow these tactics to control our behavior, but it indicates that there is a very substantial systemic problem in the US that militates against women's rights. So it's not just that women are too weak-willed to stand up to the doctors.

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  10. @Erin, totally interesting points...and so so so sad.

    Rixa, I love this post. I think that in a LOT of cases we ask permission too much. ESPECIALLY as first time mothers...we simply don't know any better half the time. Anyway, this is baby #3 for me and I am thrilled to have this one at home without apology or lengthy defensive explanations to the many people (friends, family doctors, insurance company etc.) as to why and blah blah blah...it is simply what I want to do for me, my baby and my family.

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  11. @ Anon 7:33:
    Erin already gave you a great outline on the problems with *CONTINUOUS* (as opposed to intermittent) EFM. Actually, research shows cEFM leads to MORE interventions, such as c-section, WITHOUT a corresponding improvement in outcomes. In other words, it actually does more harm than good.

    Additionally, I wanted to add that it stops you from using hydrotherapy (shower or tub) - a PROVEN effective pain-reliever with basically zero side-effects (much unlike pharmacological pain relief).

    Also, the nurses & even docs tend to focus more on the machine then you as a person - and actually may MISS OUT on potential problems! Nurses monitor the machine remotely from the nurses station & OBs can check status from their mobile phones! It's vastly superior to have a skilled human attending to you in person with the doppler - as in the case of good midwives.

    Finally, even ACOG states that INTERMITTENT monitoring is sufficient for low-risk birth. So any hospital that tells you continuous EFM is required for everyone - run screaming!

    The best outline of research I've seen on the issue was in the book, "The Thinking Woman's Guide to a Better Birth" by Henci Goer.

    As to the original post, I agree it's great. But I see several problems - as noted, you hear horror stories all the time of things being done like AROM ("breaking water") or episiotomy without even TELLING the woman, let alone first obtaining informed consent. (or in one online news horror story, even doing AROM while she screamed, "No, stop stop.")

    But also, I've read many stories where women are in such a state of "labor land" that they really have trouble advocating for themselves & are very suggestible. I can imagine if your care providers are "throwing the dead baby card at you" it would be really hard to resist their recommendations.

    But I've even read articles where home birth midwives say they are sensitive to the fact that a birthing woman is suggestible. So even placing a chux pad on the bed when a woman feels the urge to push is a subtle "suggestion" that she ought to go there to push, whereas making a concerted effort to say, "Push wherever you want" helps provide encouragement for her to LISTEN TO HER BODY instead of listening to outsiders.

    I guess in other words, I see a great continuum between care providers who try to CONTROL birth & CONTROL the mother, vs. those who make a concerted effort to help empower the mama & help her follow her own instincts.

    -Meg

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  12. @ Anon 7:33:
    Erin already gave you a great outline on the problems with *CONTINUOUS* (as opposed to intermittent) EFM. Actually, research shows cEFM leads to MORE interventions, such as c-section, WITHOUT a corresponding improvement in outcomes. In other words, it actually does more harm than good.

    Additionally, I wanted to add that it stops you from using hydrotherapy (shower or tub) - a PROVEN effective pain-reliever with basically zero side-effects (much unlike pharmacological pain relief).

    Also, the nurses & even docs tend to focus more on the machine then you as a person - and actually may MISS OUT on potential problems! Nurses monitor the machine remotely from the nurses station & OBs can check status from their mobile phones! It's vastly superior to have a skilled human attending to you in person with the doppler - as in the case of good midwives.

    Finally, even ACOG states that INTERMITTENT monitoring is sufficient for low-risk birth. So any hospital that tells you continuous EFM is required for everyone - run screaming!

    The best outline of research I've seen on the issue was in the book, "The Thinking Woman's Guide to a Better Birth" by Henci Goer.

    As to the original post, I agree it's great. But I see several problems - as noted, you hear horror stories all the time of things being done like AROM ("breaking water") or episiotomy without even TELLING the woman, let alone first obtaining informed consent. (or in one online news horror story, even doing AROM while she screamed, "No, stop stop.")

    But also, I've read many stories where women are in such a state of "labor land" that they really have trouble advocating for themselves & are very suggestible. I can imagine if your care providers are "throwing the dead baby card at you" it would be really hard to resist their recommendations.

    -Meg

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  13. umm perhaps you are forgetting law suits against mothers who haven't "allowed" the OB to preform a c/s? or the mothers who have had babies taken away because they marched out of the hospital and went home - only to have the cops sent after them and their babies taken away.

    THIS is a real concern. If you happen to go into labour with just the right hospital and just the right nurse/OB staff, on just the right day... yes, maybe you're "I can do it myself, leave me alone" attitude would fly. I've seen it work miracles! (A few clients of mine beat the odds with this very attitude! and it was awesome and powerful!) I've also seen it backfire, like when I was at the hospital (I worked on staff for a few years) and one of the moms was tired of being poked, prodded and generally bothered during her labour. so she unplugged herself, marched herself to the bathroom and locked the door for some well deserved privacy to labour for a while!
    sounds, good right? yes it was... until the head nurse called security, had them open the door and they threatened her with child protected services, a lawsuit and a trip to the psych ward. She physically forced her back into bed and emotionally beat her down by labeling her on her chart AND her door as a "combative patient". This label will follow her all of her life in her charts,BTW.

    Rixa, if things were as easy as you are making them to seem, more people WOULD do it. The whole of american women aren't just scared and wimpy - they are rightfully horrified at the idea that their child could be taken away from them. THIS is a big deal!

    Good for your friend! and good for all the women that stand up for themselves and get what they want in a hospital setting because it's NOT easy to do. But let us not ever let ourselves actually think the hospital doesn't have power on us, because it does in the eyes of the law. Maybe they wont cash in on this power... but when they do- and they often do - it can hace horrible and ghastly results!

    I think any women who is birthing in a hospital has a right to be fearful unless they are totally ok with the OB staff calling all the shots and are prepared to be totally ok with what results from those shot calls.

    (speaking as a on-staff hospital and personal home birth doula, as well as a mother of 3 whose birthed in hospitals and home)

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  14. To those commenters who worried about my making this seem too simplistic and simply a matter of women needing to be stronger...I don't think it's as simple as that, hence my caveat in the middle of the post. In fact, many people I know personally were quite knowledgable about birth, had already had children, and yet were still blindsided by authority figures telling them they coudln't do X or Y.

    Maternity care--and all the associated problems as well as successes--is a result of complex processes and decisions, some on an individual level and some on an institutional level. This post was more about affecting change on an individual level. As much as it's important to take a meta-level look at maternity care and try to change institutions and protocols, we can't forget that birth happens one woman at a time. And I do think it's important to stop asking permission for many of the things that happen in the birth room.

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  15. Your comment got me thinking about the doula's role and some of Jennifer Block's observations on the complicity of doula in playing along with the authority of doctors/nurses.

    The "bad" doula, who you learn about in training, who drs/nurses complain about, is the one who directly interferes with what the people in authority are doing. If I yanked out the monitors and got the mom up to the bathroom, told the doctor "she's not pushing on her back" and then handed her a chux pad so she could kneel on the floor - I would be in a tremendous amount of trouble. We are not supposed to do that - we are supposed to empower our clients to do that if they want to.

    Many of the doulas I know have become very explicit about that with their clients: "I cannot prevent the hospital from requiring or doing certain things. I cannot speak for you. Only you can prevent those things, and only you can tell them what you want." I went to a birth a few months ago where the mom wanted to push upright. The midwife instructed her to lie down and pushing went very quickly with the mom on her side; the birth happened smoothly. I still regret I didn't get in the (somewhat prickly) midwife's face and I feel like the parents were also thinking I would say something and were a bit let down that I didn't - but yet they didn't say anything either.

    When I told another doula about it she was emphatic that they had no right to be disappointed or to have that expectation of me in the first place. At best, I should have given the mom suggestions of ways to tell the midwife she wanted to push upright. But it still bothered me; there's only so much advocacy people should be expected to do for themselves. Empowerment on the spot only goes so far; it's very difficult for people to break out of these habits of acquiescence. If we let the feisty, educated, empowered people speak up for themselves and then shrug and say that the ones who didn't, must not have wanted the birth they said they did, what kind of system are we helping to perpetuate?

    I sense a reply-turned-post here...sorry this got so long!!!

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    1. Well said!! It's not JUST about us standing up for ourselves - the problems is that we NEED to in the first place. :( What a travesty that birthing in the US has gotten so out of control and the "system" has taken full advantage of our vulnerability as women during labor and delivery - it's shameful!

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  16. I'm training as a CNM in the US and I absolutely agree that women simply demanding what they want is often the best way to get it. Get up and go to the bathroom, eat and drink (if you are willing to take the tiny risk of aspiration if you had surgery), push on the floor. Do your thing! A few years ago I was a doula for a close friend laboring her second baby and she walked in to the hospital at 8cm, refused the IV and went straight into the shower. When asked at one point to return to the bed for monitoring she simply stated that she needed the shower and she stayed there. The nurse was doing her part to do what she has learned will keep the baby safe. She wasn't trying to be controlling. My friend refused. No problem.
    I think it's important to remember that in institutions the staff is often so entrenched that they are just doing as they usually do and are not the enemy. The last commenter Rachel regrets not "getting in the face" of a midwife. It is a tremendously rare circumstance when such behavior would be appropriate. Challenging the norm is one thing and being aggressive is another.

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  17. I read a lot prior to giving birth to my daughter, and knew that certain positions might be easier than giving birth on my back. But when it came time to push, it didn't even OCCUR to me to position myself otherwise. I was so exhausted after my long labor that all of the knowledge I had gained in the past nine months flew out the window. Pushing was not easy, and I found myself getting frustrated: why didn't someone DO something for me? It never occurred to me that *I* needed to be that person for myself. I was too exhausted to be my own advocate. In retrospect, I can see how women can be led into procedures that may be easier for the OB rather than the mother -- you are just too tired to put up a fight.

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  18. When I had my son, I choose my doctor for a few reasons, one of them being his low c-section rate, and his flat out distaste for them. I have a friend who he had to do a c-section to deliver her son as her blood pressure dropped and she lost consciousness. So he isn't opposed to them, but really really dislikes to do them. However, the hospital that I had to deliver in was very restrictive in my birthing methods. Had to be hooked up to monitors, had to stay in bed once my water broke (though they prefered me there the whole time). Wasn't allowed to eat or drink anything. I flat out refused to let them keep me in bed or not let me eat. They were firm in hooking me up to machines, but others I was able to work with them on. Sometimes it isn't always the medical staff, but hospital policy. I wish more people could be better informed of hospital policy. For me, it was almost like they tried to hide it, unless you knew what to specifically ask.

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    1. Yes but, hospital policty is not state law...we need to remember that. Ugh, I hate that we are put in positions like that that made to feel like inadequate peons at a time when we should be empowered, loved, cared for, and treated w/ dignity and respect.

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  19. Wow Rixa, I am really disappointed in how you are ignoring some of the very important messages posted here, in particular by Elle and the anonymous post before Elle.

    Threats of CPS and lawsuits are real and many medical professionals do terrorize women.

    How can individual women be agents of change when they are being terrorized and victimized and threatened by authority figures.

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  20. Rebecca, regarding the role of a doula, I do think that it's important for doula's to inform their clients of their limitations on interacting with medical staff so they know they will need to speak up for themselves. When I transferred to the hospital my midwife and her assistant basically took on the role of doula. We were able to discuss things when the doctor wasn't in the room, but when it was up to me to tell the doc yes or no on any procedure.

    I also agree that there are many obstacles in institutionalized medicine to women just speaking up for themselves. But, I also think an important element in affecting the kind of change we believe needs to happen is to encourage women to challenge, gently perhaps and in small steps, the "authorites".

    I don't think any mother should risk having her child remove from her. However, what is the harm in first saying no to test the waters? If the staff becomes combative the woman can back off and concede if she is threatened. But, as we've seen in these examples, sometimes women aren't threatened and are allowed to give birth as they see fit. If no one ever challenges the status quo, it won't change.

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  21. Thank you for this post Rixa. I have been dreaming of a midwife attended homebirth for 3 years and now that I'm finally pregnant I can't get a midwife! So it looks like I'm stuck with the hospital-prayed a lot about UC and it just did not feel right-and the idea of just doing it and not asking is exactly what I plan to do while at the hospital.

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  22. THANK YOU, Rixa!!!

    This is the kind of post I would like to see more often. Inspirational. Real. Transformative.

    Bravo!

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  23. My first birth, I didn't question ANYTHING. I had a reasonably decent experience.

    My second birth was at a birth center with amazing midwives. That experience was neat, but I found out how amazing it was compared to what could have been with my third birth.

    Third baby came REALLY fast, and I felt no pain till about a half an hour before he was born. He ended up being born at home, with paramedics there. I had to fight for EVERYTHING. They told me to get on my back, I told them I'm not here to make it easy for you. They tried to cut off my skirt (I have very limited clothing) I about flipped. Then they wouldn't let me hold him and at the hospital gave him shots and other things without my permission. I hateed everything about his birth. They even told my husband to leave!

    I will never birth at a hospital again, unless it is my absolute only option, but standing up for myself did allow for my birth to be better than it was. And it amazed me and empowered me to realize I could get what my son needed, and screw everyone else.

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  24. A little late in responding, but I really enjoyed reading your friend's story. I wish I could be like her. Unfortunately, even though I seem like an assertive strong-willed woman, I crumble as a patient. This is why I am taking myself out of the medical care model as soon as I feel I'm done with shadow care.

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  25. Oh how I wish I were brave enough! My son was breech so I had a C-section for him. I want to do VBAC with our second. But I am such a push over. If the nurse tells me to lie down I probably will. I plan to go to a birthing center this time so maybe I will have my ideal birth. Now to just get pregnant!

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  26. Do you ignore all physician's advice or just Obstetricians?

    They are the ones that you will sue if something happens to your baby during its birth, right? Even after you have ignored all of their instructions.

    I personally interviewed my OB physician and chose one that I knew was knowledgeable and experienced. Keeping secrets from and ignoring their expert advice is counter productive. If you don't want their help and expertise, then just stay home and deliver. Just be careful which midwife you choose. A friend of mine found out too late that her midwife had been responsible for several infant deaths from inadequate prenatal care and mishandled deliveries. Usually the parents of these infants are too guilt ridden to pursue charges against the midwife, so the public never finds out.

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  27. Regarding the comment about women being pushed by security to do what the doctors and nurses tell them, they simply have to cite the Emtala act and I'm sure they will think twice about forcing the woman to do something she doesn't want. A woman, like any other patient, has the right to refuse any and all treatment she doesn't want. Should her rights be violated, she can sue.

    And I hardly think it's about ignoring a doctors expertise. Which birthing position is best is hardly a question of expertise, but of opinion and by and large, convenience for the doctor. it's not unreasonable for a woman to choose another birthing position or take herself off the monitors, which, as we know, continuous efm isn't any more effective than intermittent.

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    1. Which I find extremely interesting. MALE OBs are of the opinion that delivering on the back is best - what actualy personal experience do they have delivering a baby on their back. NONE.

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  28. All of the women who agree you should do what you want and not ask permission should save the medical team the hassle of dealing with you and birth at home! Hospitals have rules for reasons not for power so if you dont want to follow them then why are you giving birth in a hospital. Not following the rules can be putting you and your baby at risk.

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  29. Fantastic post! I ended up giving birth at home with no attendants present for my fourth child simply because I knew I'd be too easily coerced by hospital staff (and I couldn't find a single qualified attendant in my area willing to assist with a home birth). Kudos to those women who can "just do" instead of asking, and actually change the system from within!

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  30. I had a bad expperience with a home birth midwife. I refused to lay on my back to push. She bullied me and threatened to leave me while I was birthing if I didn't do what she said. She pulled hard on my perinuim for half an hor while I screamed and belittled me the whole time. (it was only her causing the pain because there was no pain when her hands were off me. I couldn't get away and I still have panic attacks and flash backs. I'm so afraid to ever have another attendant because of how I was treated. The title of the person doesn't always mean they will respect you and your bodily autonomy.

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