August 1, 1993

The midwife option

By Pamela Ferdinand, Herald Staff Writer

Fort Lauderdale, Fla.

April 19, 1993, 10:10 a.m.

Margaret Dynes, her cheeks flushed, strands of long blond hair stuck to her sweaty forehead, clutches floral bedsheets printed with yellow roses.
She curls her back into a stack of pillows, parts her lips and closes her eyes as she heaves her hips and pelvis forward with the contractions.
"Ooooohhh," she moans, grunting through clenched teeth.
A midwife, perched on the end of the bed, tells Margaret to hold her breath a little bit, to save all her strength for the next one.
She asks, "How does it feel to push? Does it feel good?"
The contractions pass. "I'm so tired, I just want to sleep," Margaret says.
It will be at least five more hours before she does.

*

Birth is normal. It happens every day.
For prospective parents, though, each birth is remarkable and a little mysterious. Most feel comfortable in hospitals with obstetricians and emergency technology at their fingertips.
They don't necessarily want to use the machinery, but they want to know it's there in case something goes wrong. And things do go wrong.
Still, hospital births with obstetricians can be frustrating -- emotionally, financially and physically. Some women may find the experience daunting and the surroundings unfriendly.
More and more healthy pregnant women are choosing midwives, and sometimes home birth, as an alternative.
Margaret and Tom Dynes decided to have a home birth with a licensed midwife, Janice Heller, after two hospital births.
Tom, a carpenter, met Margaret through friends at Our Father's House church. They married and tried for a year and a half to have children. Just when they were about to give up, move out of their North Miami house and travel in a motor home, Margaret became pregnant.
Some of their friends had home births with midwives when having babies at home was "the thing to do," Margaret recalled.
But she and Tom, 22 and 25 years old when she first became pregnant, wanted the security of a doctor in a white lab coat and electronic monitors.
They anticipated the joy of seeing and holding their newborn. They did not want to take any chances.

*

That first time, five years ago, Margaret spent most of the day with mild contractions, watching the winter Olympics on television.
Her water broke on the way to North Shore Medical Center in Miami.
Nurses laid Margaret flat on her back and hooked her up to an intravenous tube to relieve her dehydration. They attached an internal monitor to the baby's head.
About nine hours later, still not dilated more than four centimeters, she groaned in agony. An anesthesiologist injected a regional anesthetic, hospital records show. It relieved Margaret's pain, but numbed her urge to urinate and her normal, instinctual urge to push.
Her bladder swelled like a grapefruit. Then the contractions slowed.
To speed labor, a nurse injected a synthetic form of the hormone that stimulates uterine contractions.
The drug-induced roller coaster caused the baby's heartbeat to drop, Margaret said. Tom watched as nurses fitted Margaret with an oxygen mask.
"My feeling was that I was in the way," he said. "I was sleeping on the cold, hard floor, nobody wanted to answer my questions."
Midway through Margaret's labor, Tom wrote his wife and unborn child a letter: “Though it probably has been foolish, I have despaired of your lives today. To sit here by your side and see all the tubes, to see your face as your body screams in pain, my heart has almost burst with love and fear and hope.”
Margaret dilated, and nurses sped her to the delivery room. They covered her legs with a sheet, propped her feet in stirrups, and urged her to push. The doctor made a cut to widen the vaginal opening.
Abigail "Abby" Dynes was born February 19, 1988, at 6.6 pounds after 34 hours of labor.
Margaret felt like she was going into shock and began trembling. She could not hold the baby.

*

April 19, 4 a.m.

Margaret's water breaks. The Dynes head to Linda and Erik Sampson's Davie home. Its lights pierce the damp, dark morning.
Linda, Margaret's best friend, makes coffee. Erik pours corn flakes for seven sleepy-eyed children. The midwife, Cynthia Feinberg, takes a mug of coffee and gets acquainted.
Cynthia is a stranger to the Dynes. Janice, Margaret's regular midwife, is on call at another birth. It's not unusual for midwives to come to each other's rescue, and Cynthia, a mother of three, runs her own practice in Miami. Without the rapport usual between midwives and their clients, she is counting on Tom to support his wife.
Her unobtrusiveness puts Margaret and Tom at ease, though they are disappointed Janice will not attend the birth.
A lullaby tape plays in a corner of the low-ceilinged bedroom. Two lamps throw shadows over an Indian quilt tossed over a bookshelf. A knickknack reads, "Happiness is being married to your best friend."
Dressed in a flowery, oversize T-shirt and white athletic socks, Margaret sits in the middle of a handcrafted wooden bed and sips water.
The midwife's birthing assistant, Marguerite Spillane, wraps a cuff around Margaret's arm and takes her blood pressure. It's normal.

*

Janice, a licensed Hollywood midwife since 1984, attended her first birth by ultimatum.
"This woman called me and said, 'I don't care, if you don't come, it's going to be me and my dog,' " Janice recalled. At the time, in 1976, she was a midwife-in-training.
She has since assisted more than 1,200 births. Most took place at homes, and only one resulted in a serious problem.
She is one of 34 licensed midwives in Florida. Also called "direct-entry" midwives, most attend home births or births at one of 21 birth centers statewide. About 329 certified nurse-midwives practice in Florida, assisting births in hospitals, birthing centers, and a limited number of homes. They work closely with physicians and are registered nurses with advanced childbirth training.
State laws now require three years of midwifery education for new direct-entry midwives. Both nurse-midwives and direct-entry midwives are regulated by the Florida Department of Business and Professional Regulation.
Unlicensed midwives are illegal in Florida.
Janice typifies most modern direct-entry midwives, who are committed to a safe birth, preferably -- but not necessarily -- at home. Midwife means "with woman," and they believe birth is a normal event, not a pathological process requiring constant medical intervention.
Janice planned a home birth for herself in 1986, but needed intravenous fluids and transferred herself to Hollywood Memorial Hospital. She gave birth to her only child, a daughter named Shanti Rose, in two pushes on a hallway stretcher.
It was no mean feat for a heavy woman who has used crutches since she had polio at age 3. Raised in upstate New York by a surgeon father and nurse mother, Janice originally worked as a massage therapist and pharmacology research assistant.
After attending births with two housemates, both midwives, she got hooked. Now, her music-composer husband takes care of their home and midwifery is a full-time job.
"You fall completely in love with the birth experience," she said. "Husbands find a great appreciation for their wives, and women really get to acknowledge their strength.
"Who a woman is and how her life works for her is really going to be how her birth is," she said. "If you are this radical, crisis-oriented person, chances are that your birth is going to be crisis-oriented."

*

April 19, 6:46 a.m.

Margaret's contractions fall three to four minutes apart. Her cervix readies for the birth, laying thin and smooth against the baby's head.
Supplies are ready, including: hot compresses, bulb syringe, umbilical tape, clamps, and olive oil. Cynthia also carries oxygen, local anesthetic, pitocin -- the synthetic hormone used to increase contractions -- and vitamin K.
Tom huddles with Cynthia in the hallway. He looks worried.
"I get the impression from Marguerite that there's something I should know that I don't know," he says.
Cynthia detected a slight fetal bowel movement in Margaret's fluid. If the baby breathes the substance, it can cause pneumonia or death.
Cynthia must rule out any immediate fetal distress by checking the heart tones. If they are normal, the light staining may be evidence of temporary distress prior to labor and there's no need for panic.
From prenatal classes, Tom knows that midwives use a DeLee suction tool to clear the baby's breathing passages after the head emerges.
“It's your call," he tells Cynthia. "If we need to go (to Memorial Hospital), we're on the way."
With an an electronic instrument that uses sonic waves to detect a baby's heartbeat, Cynthia listens to Margaret's belly.
She hears regular heart tones. They stay.

*

Abigail's brother, Jonathan, was born on March 15, 1989, at Hialeah Hospital after 14 hours of labor.
Margaret's water broke at midnight, one month early. She knew that could increase the odds of a Caesarean section, when a physician cuts open the uterus to deliver the baby.
Two years later, in 1991, Hialeah Hospital would deliver a higher percentage of its babies by Caesarean than any other hospital in Florida -- one of every four.
Margaret followed instructions when nurses hooked her to an intravenous tube, gave her a synthetic hormone to stimulate contractions and laid her flat on her back.
"They gave me an enema, then they shaved off all my pubic hair, which was ridiculous, but I didn't want to make waves," she said.
All of a sudden, the urge to push took over. She said she yelled for a doctor, but the nurses shouted not to push because she was not yet 10 centimeters dilated.
"That baby came out in two contractions and probably could have come in one if they weren't telling me not to push," Margaret said.
A borderline preemie at 5.14 pounds, Jonathan was taken away, and Margaret said she did not see him again until the next day. No one told her why her waters broke early.
"What happened with Abby helped prepare us for what happened with Jon-Jon," Margaret said. "You're so alone, so isolated from people who care about you."

*

April 19, 7:30 a.m.

Margaret leans against a bedpost and sips Carbo Fuel, a high-carbohydrate drink.
The contractions strengthen. She is restless, hot and sweaty. Her legs feel like jelly.
“You look so beautiful," Tom tells her. A friend's 6-month- old baby cries in the next room. "Hearing him is a perfect sound."

*

After what they considered two unpleasant births, Margaret and Tom chose home birth with a midwife for their third child.
Margaret's best friend, Linda, gave birth to four children at home with Janice.
"I knew how good she was, just from Linda," Margaret said. "But there's always that element of fear until you have a home birth and get to know the midwife."
She and Tom loved the idea of having a child surrounded by family and friends. Cost was also a factor, she said.
The first birth, not covered by insurance, cost $5,000; the second, which was, cost $500 in co-payments. Janice charges $3,200, with a sliding scale for clients who cannot afford the full fee.
So, on Tuesdays, Margaret joined the steady stream of women who flowed through Janice's clinic door.
"I just don't trust (the hospitals)," said Margaret, worried at 30 weeks into her pregnancy about another premature delivery. "I feel that you know much more about what you're doing than they did."
"That's nice of you to say, but it's not really true," Janice said. "We just talk more."

*

April 19, 8:30 a.m.

The contractions come faster. Margaret's belly tightens. She releases great whooshes of air.
"I'm trying to relax, but it's hard," she says.
Marguerite recognizes this restlessness as a sign of transition, the dilation period from six or seven to ten centimeters when a woman struggles to concentrate -- the time when some women report out-of-body, near-death experiences.
"Don't worry that you're having trouble focusing now, it's part of the process," Marguerite says. "The contractions are getting hard, the baby's advancing."

*

As a state requirement for direct-entry midwife care, Margaret and Tom attended a seven-week session of prenatal classes.
"It's important that you're comfortable with your midwife," said their instructor, Hollywood midwife-in-training Debbie Marin. "If there's something she's said to you or done, you have to be up front with her."
She and Janice weed out parents who may be inappropriate, and unsafe, for home birth. They don't take women who smoke, drink or use drugs. They don't take people who are uncommunicative and uncommitted to prenatal care and breast- feeding.
"You can't go home with them and say, 'You have to eat right,' " Debbie said. "They have to be responsible people."

*

April 19, 9 a.m.

Margaret lies on her left side with a pillow between her legs to relieve her lower back pain. The contractions follow one after another in less than a minute.
In the living room, Erik plays guitar and sings to the children.
"Once there was a windy day, a beautiful day to have a baby. A lot of people came to help out," he sings.
Cynthia presses a warm compress between her legs, stimulating circulation and making the tissues more supple and more liable to stretch, not tear.
“Oh no, oh no," Margaret moans, her legs quivering.
"Your body knows just what to do," Cynthia says. "It's perfect."
“Look at me, OK, OK, yeah, sweetheart," Tom says, massaging her back.
Linda kneels on the bed and bows her head, eyes closed, praying.

*

On this clinic day in late March, Margaret, bags under her eyes, looked peaked.
"Your iron's 11.9," Janice said. "You're doing real good."
"We're on top of this," Margaret said. "It's very comforting."
She has decided to give birth at her best friend's house, where she feels most peaceful.
"So what's my next clue?"
"Your next clue is probably going to be contractions."
Margaret laughed and said, "Good clue."

*

April 19, 10 a.m.

At the end of a contraction, with two gloved fingers, Cynthia feels and notes the condition of the cervix and the position of the baby's head.
As the next contraction begins, she moves the lip of the cervix up and away, out of the baby's way.
The baby's damp brown hair peeks between Margaret's legs and retreats. Margaret reaches down to touch his head, then pushes.
"A couple more like that and you'll be done," Cynthia tells her.
"I wish."
Marguerite briefly fits Margaret with an oxygen mask for energy.
Cynthia lifts Margaret's legs and slips a clean absorbent pad underneath her. When the baby is born, she will remove the wet, blood-soaked pads. The bed will be spotless.

*

The baby won't come unless Margaret and Tom resolve any tension between them, Janice counseled Margaret as the due date, April 10, approached.
Birth is as much emotional, mental, psychological and spiritual as biological, midwives believe. Janice suggested they go on a "date."
During Margaret's past two pregnancies, Tom did not confront the emotional trauma of childhood sexual abuse by his mother, who later committed suicide. Nor did he discuss doubts about his ability to be a good father, which made it difficult for him to bond with his own son, Jonathan.
When Margaret's sonogram showed their third child was a boy, he felt disappointed at first. But this time, he and Margaret discussed their concerns.
"Nothing is hidden," Tom said, during their Saturday night "date" at Steak and Ale in North Miami.
"Our relationship goes deeper," Margaret said. "I've been much more excited about being a mother again."
They shared, too, their expectations about a home birth with a midwife.
"I look forward to being around people I love, playing my own tapes, being able to eat and drink and take a hot shower or bath," she said.
Tom said he was torn.
"I'm a real private person, I don't even want the midwife there," he said. "But this other part of me wants people who love me and people I love near. I want it to be like a holiday."

*

April 19, 10:40 a.m.

Cynthia massages Jason's emerging head and the surrounding area with olive oil.
With her fingers, she eases the pressure around the top and bottom of the vaginal opening and checks his scalp color for pinkish-blue or purple tones, both good signs.
She clears his mouth with a suction and feels for an umbilical cord around his neck. She finds part of the cord.
In a split second, she slips a finger down along the back of the baby's neck, flexes the finger and grasps the cord. With her other hand, she unwinds it.
Neither Tom nor Margaret notices.
“He's so beautiful, honey," Tom says.
Margaret's face is transformed.

*

With the baby overdue by nearly a week, Janice and Margaret spoke about God and accepting that she cannot control when he will be born.
"By next week, if you haven't had the baby, I'll have to do an ultrasound," Janice said. "You would probably be induced by now if you were going to an obstetrician."
Her guess, after an internal exam: Jason will be about 7 1/ 2 pounds.
"There may be a minute or an hour when you get really blue and think you're going to be pregnant forever," Janice empathized.
"Before it was like, it's going to happen today," Margaret said. "Now it's like, is it ever going to happen?"

*

April 19, 10:48 a.m.

Jason pops out, a limp white body, a blood-streaked reddish face.
Tears stream down Tom's face, "He's perfect."
Cynthia massages the baby into movement. He cries, and she wraps him in a blue towel and places him into Margaret's arms.
"My baby, oh my baby," she whispers.
Linda cuts the cord.
"I'm so glad it's over," Margaret says. "I was so scared I was going to have to be induced again."
Cynthia weighs Jason with fisherman-type hanging scales, suspending the baby like a stork with its bundle.
Jason Dynes is seven pounds, eight ounces.
"If we had gone to the hospital, they would have whisked him away," Tom says.
"This was a total healing."