I'm Cynthia Overgard, birth educator, advocate for informed consent, and postpartum support specialist. And I'm Trisha Ludwig, certified nurse midwife and international board certified lactation consultant. And this is the Down To Birth Show. Childbirth is something we're made to do. But how do we have our safest and most satisfying experience in today's medical culture? Let's dispel the myths and get down to birth.

You're a mother who's had four complicated births under midwifery care. I think you were motivated to talk to us because you wanted women to understand that midwifery care can often be appropriate, if not ideal, for complications. Why don't we begin by you just quickly telling us the complications you have faced in your birth experience?

Sure. I've had four births, and out of my four births, I've had preeclampsia three times. I have had two delayed postpartum hemorrhages. I've experienced varying degrees of postpartum depression twice. I had a thyroid disorder that was diagnosed immediately postpartum. I experienced a year of secondary infertility, and during the course of my care under midwifery care, I was also given support through a luteal phase defect sort of PMDD kind of diagnosis. It's one of those nebulous ones that's hard to pin down.

I've had the spectrum of well-woman care, the spectrum of birth care and postpartum care. As far as my babies are concerned, all four had tongue ties, cheek ties, or lip ties as well.

Wow, you've had a lot of experience with some of the challenging things that can come up in pregnancy, postpartum, and breastfeeding. Were your births attended by nurse midwives, or are we talking home birth, out-of-hospital type of care?

All four of my births were with CNMs, but I have had a planned hospital birth, a planned home birth, a planned birth center birth, and then a planned birth center birth that was a hospital transfer.

Great. So where do you want to begin?

Well, I want to say first of all that I think all births can be good, and all births can have a lot of joy and a lot of thankfulness. I want to be really clear that even though I want to share that this was a part of my birth story that I wouldn't want to replicate or wouldn't wish for your listeners, I didn't feel like any of my births were just straight-up bad. There was nothing I would go back and say, "Well, I just hate that I had that, and I wish that had never happened to me," because I have four really wonderful children that came out of it.

That's definitely the part that I'm most excited about sharing. If you are a person who's getting ready to have a birth or who has had a birth in the past and you're considering what's next for you, midwifery care has been, at least for me, tremendous. It's been everything that I hoped for, and it's definitely informed the directions my births have gone.

My husband was present at three home births before we got married—his three younger siblings—so he had a super positive view of birth. We were very pro-midwifery, pro-home birth, pro-birth center birth, all of that from the get-go.

Because I had these health complications, we weren't sure pregnancies would be easy for us. We weren't sure it would be easy for us to conceive, and we weren't sure it would be easy for me to carry a pregnancy to term. We asked ourselves, what can we do that increases the amount of joy we have and the amount of support we have, without taking away from our ability to have the natural births we were hoping for?

My mom is an amazing woman. She's had four births, and three of them were super medicated and medicalized, and she always spoke very positively about those. But when I was in middle school, she had her last birth, and that was all natural. I was around for that, so I was around midwives and doulas, and it was just so inspiring.

My mom, unlike so many other moms who say, "Oh, when you experience this, it's going to be terrible," always communicated from the time I was very young, "I can't wait for you to experience this. Birth is so good, and it's so transformative, and it's how our bodies were created and designed. As a woman, as a mother, as a wife, it's so powerful."

That was the reason we decided, from the very beginning, to work with midwives in our family despite the potential for these complications.

My first birth had no complications until I ended up with a very late-term diagnosis of preeclampsia. I was over 41 weeks at that point, which didn't concern me because I know first-time moms often go that late or later. But that set me off on the course of asking, what does it look like to give birth under midwifery care even with major complications? I had pretty severe preeclampsia, and it was still so worthwhile.

Were you induced for that birth or any others?

I have been induced twice.

Catey, with a late diagnosis at 41 weeks and what you described as pretty severe preeclampsia, this was a planned hospital birth with a nurse midwife?

Yeah.

Tell us how that unfolded. Did you end up being induced? Did you go into spontaneous labor? What happened during the birth, and what came out of that experience?

I came in for my standard midwife appointment and a biophysical profile at 41 weeks and two days. I actually was feeling fine at that point. I didn't feel particularly bad, but when they took my blood pressure, it was really, really high.

We waited about half an hour in the office and retook it, and it kept getting higher and higher. I think I came in for that appointment at just the perfect time because I wasn't yet symptomatic, but my blood pressure had gotten really high. We did a urine test, there was definitely protein in my urine, and things were progressing.

I'm a person of faith, and when I look at that, I say there was protection over me and guidance for me, and I'm so grateful because that appointment had actually been rescheduled. I was supposed to go in the next day, so I was very grateful that I came in when I did.

At that point my midwife came in and said, "I don't really feel like we have the option," because my blood pressure was already high enough that I would need magnesium at the hospital. She said, "I don't really feel like we have the opportunity to let you go into spontaneous labor. This is truly one of those cases where we're grateful for modern medicine and grateful for these more intervention-heavy births."

I met my husband and my mom at the hospital—I drove myself—and we started an induction with a cervical ripener. It just wasn't progressing fast enough for how quickly my blood pressure was escalating, so I ended up needing quite a bit of Pitocin. I also had magnesium and blood pressure medication.

I was able to have a vaginal birth, and I did not have an epidural, which was very challenging, but I was so glad. Especially with it being my first birth, I think that would have set the tone for every experience I had with my own body as a mother and with any later births if I had felt like I hadn't been able to preserve any of the hopes I had for my birth plan.

I had excellent midwives who advocated for me. They let me eat and drink and labor, which is pretty uncommon when you're on magnesium. They advocated for different position changes even though I was on pretty strict bed rest, and they were really present through the postpartum while I learned to nurse.

I had really strong reactions to the magnesium. That's a pretty challenging drug to be on, at least in my experience and from what I've heard from other mothers. I was very grateful for the opportunity to feel like there was still an element of the natural birth I was desiring, even with these life-saving medications that I had to be on.

I really like how your midwife presented the scenario to you when she said, "We really don't feel we have the opportunity to have spontaneous labor," instead of saying, "You have severe preeclampsia. Your baby is at risk. Your baby could die. This is life threatening. You need to go to the hospital now. You need to be induced."

She really presented it to you in a way that allowed you to still feel like there was a decision you could make.

Absolutely.

The way she framed it.

I had preeclampsia twice after that, and each time we made the decision together. I really appreciated that as well.

That's very uncommon because preeclampsia can progress very quickly, and it is something very serious, especially when it's severe. Under different care, you very well could have been coerced into a rapid-fire C-section.

The other thing I want to comment on is how remarkable it is that you had a non-epidural birth on heavy doses of magnesium sulfate, with preeclampsia, high blood pressure, heavy amounts of Pitocin, and staying in bed. Just so women know, it's possible. It's very hard to do because you didn't have the freedom to get up and move. One of the ways we get around Pitocin and some of the things that are more challenging in labor is to be able to get in the shower, move, and walk. To be in bed and still get through birth that way—that took a lot of courage.

I wanted to make a comment about epidurals because when you said the word epidural, I realized the very first word that always comes into my head when I hear it, and I think this is going to surprise people.

The word is tool.

I view an epidural as a tool. I've had many clients over the years who had preeclampsia and declined the epidural because they were relying on deep relaxation techniques and didn't want anything disruptive, and it worked for them.

But I do want listeners to know that I liked how you described this, Catey—that it was the part of your birth you could preserve. I think that was a very powerful statement.

I also want women to know that there is a point where virtually any of us would get an epidural. Virtually any of us would raise our hand and say, "Can I please have this tool to allow me to either relax, maybe get a little nap, or just change the course of my cyclical thought process?"

Even though I've had two physiologic births, I don't view it as, "Oh, I managed without the epidural." Birth, since the beginning of time, has been without an epidural. It's only when we view birth through the frame that it comes with an epidural that we say, "Oh, you did it without it."

Birth comes without it, but it is an available tool, albeit with some risks. It makes sense for a lot of women and might make sense for any of us if birth lasted another ten hours or if we went into labor right before a night when we desperately needed sleep. I just want listeners to frame it that way because I think it's accurate and reasonable.

It becomes an especially helpful tool when you have interventions in birth. I think that's the difference. Physiologic birth is naturally without an epidural, but once you start intervening with heavy doses of powerful medications that dramatically change your physiology, an epidural becomes almost a necessary tool.

Yes.

For my fourth birth—that was my hospital transfer—I had preeclampsia again. I was only 38 weeks. My labor lasted much longer. My first birth wasn't short, but my fourth birth was much longer.

I had been at six centimeters almost the entire time—about twelve hours—and I wasn't with my midwives. Our laws changed in the state where I live, and they were no longer able to be there, so it was a full hospital transfer under OB care.

I had a wonderful nurse from my church who was training to be a midwife and agreed to come support me as part of my birth team. She was incredible and, in many ways, helped preserve the kind of birth I wanted.

When I'd been at six centimeters forever and was becoming progressively more preeclamptic, with high levels of Pitocin and a head cold, I just felt miserable. I was starting to become very afraid, and I was becoming disconnected from both my body and my baby. That scared me. I was having a hard time even thinking about the fact that there was a person I was giving birth to.

I actually asked for an epidural. We waited hours before getting one. My husband and I made the decision together with the nurse, saying, "We'll give it another hour and then check in again."

After another hour I still felt like I couldn't do it. I was scared. I couldn't manage everything with the preeclampsia.

Eventually we decided on the epidural, and wouldn't you know it, as soon as the anesthesiologist walked into the room, I had a spontaneous fetal ejection reflex and gave birth. There wasn't even a doctor in the room.

I was very grateful because I didn't really want the epidural in my heart of hearts, but that experience showed me how meaningful it can be as a tool. At that point, having no epidural wasn't preserving the birth I wanted any more than having one would have.

I also felt it was a special blessing not to have needed it in the end while still having compassion for making that choice. It's why I never look down on that decision when I work with other couples or talk with other moms.

So your body just made it happen right as you were about to get the epidural.

Yes.

But you also live with that humbling acknowledgment that you understand why, sometimes, it makes sense.

Yes.

I think that's such a cool story.

I'm so grateful. I went from six centimeters to the baby exiting out of my body in less than twenty minutes. Truly, when people say things can change fast, they really can. But I'd been at six centimeters for so many hours that I couldn't process that as an option anymore.

I'm so glad it happened.

Did you say that was your fourth birth?

Yeah.

So you were probably not actually in active labor until you got—

I was on a whole bunch of Pitocin, and I had been having contractions every sixty seconds for about six hours.

Sorry—I should say you probably weren't in active labor until you got past that six-centimeter threshold, and then you went from active labor to baby in a very short amount of time.

But it feels different on Pitocin. It feels like active labor because the nurse attending me—she may have already completed her nurse-midwife certification—said, "Oh, it's so great. You finally hit active labor, and things can change really quickly."

In my mind, though, I'd come off a home birth and a birth center birth that were pretty undisturbed despite complications. Pitocin does feel different. Hearing that was difficult because I thought, "This feels like immediately before pushing a baby out," but it wasn't the same.

Labor doesn't necessarily feel harder in active labor than it does in early labor. It's really just a technical term defining when you should start progressing more quickly.

That makes sense.

Can you explain, since you've experienced both, what labor felt like with Pitocin versus physiologic labor?

I think the main difference wasn't actually the sensations in my body because contractions felt fairly similar. They varied in intensity and length, but the biggest difference was that when I'm laboring with Pitocin, my brain doesn't catch up the same way it does when I'm laboring without it.

With my middle two births, I didn't need Pitocin. There was an element where you just felt things more than you thought about them. I know you two have talked about this a lot, but I could go hours without wondering how long I'd been in labor.

It was very intense. I had one baby who was OP my entire labor, and I had prodromal labor for about eight days, so I know what an intense natural labor feels like. But I felt like my mind could work with my heart more easily.

With my Pitocin labors, everything felt regimented. Whether I felt ready or not, here came another contraction. Whether I felt it was accomplishing anything or not, here came another contraction.

I definitely felt like I had to work harder not to become afraid.

That's so interesting because it's actually true. Oxytocin initiates labor, but it also has a profound effect on the brain. Anyone who's experienced being cuddly and blissed out after making love knows that's oxytocin.

In childbirth, even though it's incredibly intense, you're getting these waves of oxytocin that deeply affect your brain.

So that was the distinction you felt?

Yes.

I never thought you'd say that. I thought you'd say the contractions felt different, but you actually felt it in your brain.

Connection is the word I'd use. My whole body felt connected, whereas with my Pitocin labors there was just a lot more fear.

We talked in detail about this in our episode with Sarah Buckley on oxytocin and the differences between oxytocin and Pitocin. If anyone wants to learn more, definitely listen to that episode.

Oxytocin is actually released in your brain during labor. Pitocin isn't. So you're exactly right. When you're under the influence of your own oxytocin, you're more in sync with what's happening, and you have the natural physiologic response, including the beta endorphins that help balance the intensity of contractions.

With Pitocin, it's not under your own physiologic control and doesn't influence the brain the way oxytocin does.

I think that contributes to Pitocin contractions feeling more painful. As far as what was actually happening in my body, though, the contractions were more similar than I've heard some people describe. They certainly were more painful, but I think that was because there was a lack of connectivity. My brain wasn't online the same way.

How do you think your birth stories might have evolved differently had you been with a traditional mainstream American obstetrician?

I definitely don't think I would have been given the opportunity to have out-of-hospital births with my second, third, and fourth babies after having severe preeclampsia.

My understanding is that with a traditional Western OB, once you've had severe preeclampsia, you're considered high risk forever.

I felt like I received so much preventative care. It wasn't just, "You can take aspirin." That was one option, but I was also given dietary recommendations, acupuncture referrals, chiropractors to see, and all sorts of other support.

With the two hemorrhages I experienced, we focused heavily on prevention during my later pregnancies.

During my second birth I was borderline for preeclampsia, and I was encouraged to go to acupuncture instead of being induced. I think that speaks for itself. There was an understanding that many different things can support the body, and that having a one-size-fits-all, "Sorry, your birth plan is out the window," experience isn't the only option.

Another thing I experienced with my midwives was that they listened to me. I really appreciated that I was never talked down to.

I was 22 when I had my first baby, and I looked like I was 14. At the hospital people treated me like a little kid. They asked a lot of questions about my finances and not many questions about my birth preparation or my hopes for my baby. They actually didn't talk to me much about my baby. It was more, "Well, you want this, that, and the other thing, right?"

I was thinking, "I'm making decisions for another person right now, and those decisions affect them."

I never felt that way with my midwives. I always felt trusted. They understood that I had knowledge to bring to the table and that I'd done my research.

I never felt coerced or trapped. Even when I had preeclampsia, it was, "We still have options. Not as many as before, but we still have options, and we want to help you have the experience you're looking for. We trust you to make wise decisions for your body."

That also applied to my husband. When we were working with OBs at the hospital, they largely ignored him, even though he's very well educated and an excellent birth support person.

Numerous times I had to say, "I'd actually like to talk to my husband about this. This isn't just a decision between me and this OB I've just met. This is a family decision."

With the midwives, it was always, "We want to give you time. We want to give you privacy to make these decisions, and we want you to be able to make them together."

Catey, had you been seeing these midwives before becoming pregnant? Did you go to them for annual exams or other well-woman care?

I didn't, but I have since.

And did you have the same midwifery care group throughout all four of your pregnancies?

I did.

Yeah, so there's really a lot to be said for continuity of care with the same group. It may not be the same midwife all the time, but the same group, hopefully slightly on the smaller side.

So much about what you have described in all of these different birth experiences has to do with the relationship you built with the midwives, not just the clinical aspects of your care. Then there's mutual trust, and when you have mutual trust, like in any relationship, in your healthcare relationship, there is much more mutual decision-making and respect and consideration, and thinking big picture, long term, and not so much just about the care provider looking out for their own liability or what's going to cover their asses.

The fact that the obstetrician ignored your husband says so much. It says they don't respect your husband. It also says they don't respect you, because when you respect the woman, you respect her worldview and her perspective. You should know that for any woman, she's going to be turning to the love of her life, who's standing at her side, who's responsible for the outcome of this birth as she is. You're responsible for the giving birth part, but your husband is equally responsible for the welfare of the baby, and his interest is in your welfare. The fact that they ignored him is so sad that that's happening. It's upsetting.

I wanted to ask you what I think is another very important question that is just so often overlooked and rarely comes up in birth stories. You mentioned that you had postpartum depression twice. I want to ask you a little bit about this.

We don't know what causes postpartum depression. We do know of a very long list of risk factors. I'm curious to know if you identified any overt risk factors, and often how the birth goes can be one of those, or breastfeeding struggles can be one of those. Then I want to know if your midwives knew even the first thing about it, because most midwives don't. What I commonly hear is obstetricians handing out prescriptions or dismissing it as the baby blues, or midwives sort of offering the same thing, maybe saying, "But you're not going to do anything, right?" They're not trained in this. So what was that experience like for you?

Sure. I had postpartum depression after my second birth, which was my least complicated birth. It was my home birth, and it was four hours. I didn't have a single cervical check. It was wonderful, in many ways like what people imagine for themselves.

Then my fourth birth was very, very complicated, and I definitely had some traumatic experiences at the hospital, in particular with the medical care team I had there.

With my second birth, the risk factor was that I had a thyroid disorder. I was diagnosed with hyperthyroidism in the immediate postpartum. That did resolve on its own, but I know those two go hand in hand. There were relational dynamics with members of my community and things going on, so certainly it was a higher-stress postpartum, but it wasn't unheard-of high stress.

I felt a lot of guilt over being depressed during that time for a while because it was this perfect birth on the outside, and I didn't have any breastfeeding struggles or anything like that. I now can look at that and know it gave me compassion for the women I work with and the families I work with, so I'm grateful for the opportunity to have a greater amount of compassion and empathy. I did also have something going on in my thyroid that was making me feel kind of crazy.

With my fourth birth, the risk factors were very obvious. I had a hospital transfer. I lost my birth team. I had a severe delayed postpartum hemorrhage, like eight hours later, where they told me that if I passed out, I might wake up without a uterus, which was such a scary thing to be told while he was scraping blood clots out of the inside of my body. It was a scary situation. That one had a lot of the typical risk factors there.

But my midwives actually took very good care of me. Medication was always discussed as an option if that was something I wanted, but they gave me options for working with a counselor or therapist, talking with them. I spent over an hour talking with my midwife to debrief my fourth birth. She wasn't even there.

I also had the opportunity to do some postpartum care at the birth center that I would have had traditionally if I had given birth there. That helped make the experience a little more cohesive. I was given dietary advice. I was given referrals to pelvic floor therapists and massage therapists.

I actually felt like my care was extremely complete there, and it gave me the confidence to be able to tell mothers, "You can talk to someone if you are feeling unlike yourself. Even if you're not severely depressed or severely anxious, it's okay to talk to people who you trust."

Certainly I know not every midwife is as trustworthy, but in my case they were very much so. They were very compassionate and very well informed. I don't know if that was education they had or if they self-educated, but I'm so thankful because I know that, especially with my second birth, I would have come in and never wanted to talk to them again if they'd been like, "Well, as long as you're not planning on doing something super crazy."

Yeah, it sounds like they went through a very helpful list of possible things to address. I like that debriefing the birth was one of the first things there because I think that's extremely important.

It's like this elephant in the room of postpartum. It's all women are thinking about, like 18 to 20 hours a day postpartum, even after the birth, when they're adjusting to having a baby. There is so much to process with a birth, and we need many, many months to process it because you can't accelerate the processing. New emotions rise up to the top after many months, as any woman who's given birth can attest to.

The only thing I would like every listener to hear, and I think is important to mention, is rule number one of postpartum depression is removing isolation. That woman is feeling like she's in it alone, and we're not talking about the nature of her relationship. There might be tons of support, very good support, but she needs other women. Not just a support group, which is proven to reduce the duration and the intensity, or even prevent postpartum depression, but even one single friend.

When I have women in my postpartum support group who make a new mom friend, they look like a woman who just fell in love. They're on a high. They start chuckling spontaneously and talking about her unnecessarily. It is life-changing to make a mom best friend.

I'm telling everyone who's listening, even from your husband's perspective, medical providers' perspective, we have to make sure that woman has a group or a friend. It has to be their purpose and objective to find one for her, to find a group for her. They have to be like-minded, because you get more isolated if you're just joining random groups and you don't feel like you fit in with them. You just have to be on a mission to get that community.

I agree. I think that's excellent.

Catey, in the case of your postpartum depression that was linked to postpartum thyroiditis, once that was diagnosed, did it resolve by taking thyroid medication, or was it lifestyle changes, or just time and recognizing what might have been contributing to it? Was there anything you could share about that experience?

Sure. That is one thing I would say my midwives also did well. Any time I was low mood, they would always do my labs, and I appreciated that. It wasn't just me begging or something like that.

I definitely had hyperthyroidism going on at that point in time, but it wasn't so severe that we needed to jump immediately to medication. I started taking some supplements and being a little more attentive to how I was eating because I was depressed. I don't think I was eating enough, so it wasn't like, "Oh, you need to completely overhaul," so much as, "Can we make sure that we're actually getting full food groups and things like that?"

I started being attentive to that, and then they helped me schedule my follow-up appointments with endocrinologists and things like that. It actually resolved within six months, so I don't think it was very severe as far as the lab numbers, but it was very severe to experience at the time.

And it's a really common thing for women to experience. It's very common for the thyroid to become hyper after pregnancy and then ultimately become hypo after that, and then it sort of rebalances.

How did you resolve the postpartum depression with your fourth birth, where there were so many more complications around your birth? What was the key factor, or was it just a function of time?

Some of it was a function of time. A lot of it was what you were describing earlier, Cynthia, just having a really strong support community.

I took a break from teaching classes because it was so tough to talk about birth without feeling either cynical or upset or scared as I was processing some of those things. I'm really close to my mom and my sisters and other members of my community who have experienced natural birth and also, in some cases, complicated births. Just being able to talk to not just a professional, but real friends, like you were describing, was very, very helpful.

A lot of it was being able to sit with it and not try to explain it away. I've shared a lot of gratitude when we've talked today, and I'm very honest about that. That's very truthful. But there was a period of time where that would have been very untruthful for me to say, "I'm so thankful that I had this experience. I'm so thankful that I had this type of care."

So not feeling the same amount of pressure to immediately put a shiny bow on it and instead being able to say, even with hope, "I have some grief over that experience. It was really frightening for me, and it was not how I would have chosen for my third daughter, my fourth baby, to come into the world. That's not what I wanted for her either. But I know that someday I will be able to look back on this with gratitude, even if that's not right now. So I take hope in the future, knowing there's a little bit of grief in the present."

That last thing you just said, I'm so happy women can hear that because we sit with women who are very traumatized from birth. It's something we care a lot about, and they wouldn't believe hearing a woman say that the perspective changes. It's not that you would wish all over again to have a difficult birth, especially for your baby. That's where the guilt comes in. But the perspective changes. It goes from something that's not okay to being okay.

And I want women to know that if they have had a traumatic birth, it's not typically because they're a bad mom and they've done something wrong. I think in the natural health community, I'm so grateful that people are so quick to say you have sovereignty and you have the ability to affect the outcome of your birth and your baby's life, but sometimes that can look like, "You have the birth you deserve, and if you had a bad birth, you probably deserved that."

Instead, you have the ability to make choices and changes, and yet being a good mom with whatever circumstances you are dealt is if you do it with love.

Oh yeah. This mindset, I don't even know where it comes from, that if something bad happens, you deserve it. That's not how life works. Life presents us with immense challenges, and it's all part of our journey. In my opinion, it's truly how much our soul was intended to grow in this lifetime, and that's why we have the challenges we have.

When wonderful things happen, it isn't that we earned every word. It's like we get to coast for a while, and then we grow for a while. I think that's the nature of life. It's why we appreciate being human beings. It's to have a rich emotional experience, and I think suffering comes from expecting it to be just the same couple of positive emotions all the time. I think suffering comes in when that's what we expect from life all the time. We have to embrace the growth when there is difficulty.

Well, it's actually how our soul expands. Without going through difficult things and without experiencing struggle or suffering, we don't evolve.

Yeah.

We stay the same, and who wants that? Nobody. It's great, always evolving.

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