You need “shadow care?”

Many women who plan homebirths feel the need to consider the question, “Do I need ‘shadow care?'”  What exactly is shadow care, and when might you need it, want it, or not?


I take shadow care to mean accepting obstetric oversight, planning to birth at home, but not telling the care provider about plans to birth at home.  I distinguish this from concurrent care which means that both woman and care provider are engaged in an open, consensual, and honest relationship.  For those of us who have planned homebirths while maintaining some sort of relationship to a medical care provider, the best situation is to have concurrent care.  However, it would be naive of me to suggest that all women will be able to enjoy this relationship.  Most OBs will not or cannot back up homebirth midwives.  So I recommend entering into this ‘care triangle’ very carefully and cautiously.


Here are a list of situations that have prompted women to seek shadow care:

  • Desire for medicinal-grade pharmaceutical therapies/treatments for things like low progesterone, insulin-resistance, blood pressure issues, etc.
  • Desire for viability ultrasounds in the 1st trimester; desire for the 20 week ultrasound; desire for a biophysical profile late in pregnancy
  • Desire to be treated like human beings when hospital transfer is necessary during or after birth
  • Desire for continuous care if/when transfer from homebirth care to hospital (obstetric) care becomes necessary
  • Desire for a ‘contingency plan’ for if/when labor presents unexpected variables

WHEN YOU MIGHT REJECT SHADOW CARE (or someone who suggests it for you)

  • If your midwife suggests shadow care, you must must must get to the bottom of this request
  • If you suspect that your midwife is ‘using’ your shadow care as her backup care – that’s why midwives should carry insurance; if you can’t get to the bottom of this issue, find a different provider
  • If you are experiencing unwanted or unnecessary pressure from friends, family, other care providers that are unsubstantiated


  • It is unethical for a care provider to abandon you for any reason in your final month of pregnancy – speak up!
  • Investigate your options as thoroughly as possible in the time you have remaining in your pregnancy
  • Distance yourself from the care provider (and his/her network) for the duration of your pregnancy & post-partum period – don’t invite them into that special time!
  • Consider filing a complaint – to the hospital, to the local board of doctors, to the local board of midwives, whatever is most relevant
  • Make sure other families in your sphere of influence know about your experience

I welcome your input on this post via comments.  Please understand that I am not a medical doctor or someone who is in a position to offer medical advice.  I’m offering advice as a mother who has had to deal the BS mentioned in this article or know other women who have been dealt with unethically as a ‘patient.’

Empowered Birth Week

I’ve been so overwhelmed with the start of a new academic year, raising four young daughters, and trying to reserve some time for fun . . . that I have neglected other important aspects of who I am.  I am this blog!  And I am an empowered birther!  Are you?

Even if you had pain meds . . . or an induction . . . or a cesarean . . . you might have had an empowered birth.  Who decides what constitutes an empowered birth.  YOU DO, and don’t you forget it.  It’s not for medicalists or luddites to determine though many are happy to throw in an oar.  You have to be ok with your birth experiences, and if you’re not, I encourage you to figure out why and try to resolve that.

Did I have an empowering birth experience?  I suppose the answer depends on the moment you ask me about it.  Sometimes I think that if I had gone a different direction in terms of care providers that I’d have had a birth experience perhaps more resemblant of the one I so deeply desired.  Sometimes I think that my pain-in-the-ass, scare-tactic OB was an angel.  He was the best birth coach ever, as far as I’m concerned, especially considering that I had NO idea where my ass was nor how to push from that imaginary ass.

And it’s ok to struggle with being ‘ok’ with your birth experiences whether they are au natural or full-service medicalized.  It’s ok to question (or not) the validity of your birth choices (or the choices made on your behalf).  Wherever you are on the spectrum, I encourage you to think of yourself as an empowered woman.  You have the power to be fully present and accepting and/or participant in your health care decisions.  For me, being fully present and a participant are at the heart of being an empowered ‘patient.’

On Becoming a Birth Activist

I’m surprised that more people don’t ask me how I became such a “questioner” of the maternal-fetal care system.  So I’ve had a couple of cesareans, but it’s not like I work in a health-related field.  What does opera singing and being a professor of music have to do with health?  More than you might imagine.

2004 – I was pregnant with my first child; I did all of the ‘right’ preparations – I chose a CNM over an OB based on the recommendation and experience of a good friend (such a RADICAL thing to do . . . choose a midwife over an OB!); I took childbirth education classes from an independent educator; I took prenatal yoga classes and stayed in pretty good shape for most of my pregnancy.  As far as I knew, the baby should have just ‘fallen out’ after all of that good preparation.  But it didn’t.

My hindsight quarterback post of this birth experience is posted here, but let me tell you how it made me feel.  Actually, after the stomach flu > labor and dilation from 0-9cm in mere hours > AROM to speed things up and end my misery > cesarean . . . I felt like a rock star.  It was the most intense experience of my life, and I ROCKED.  Just ask my hubby!  He still talks about how I went to some ‘place’ he never new existed.  I broke a ton of blood vessels in my eyes (yes, I was ‘purple pushing’ but no, I wasn’t only pushing ‘high’).  I was still violently ill after the cesarean.  I had to send the baby to the nursury some.  My hubby had to leave because he caught the GI ‘death and destruction’ bug too.  (So did MIL!)  A lot of things went wrong . . . others were just far from ideal, but whatever.  I survived and a lot of things went right too – I recovered quickly from the surgery; breastfeeding was easy for me and my DD.  I was performing by 8 weeks post partum and took a few on-campus final interviews for University jobs.

Feb 2005 – I had my post-partum appointment with the doctor who performed the surgery.  For the first time, and I don’t know why this was the case, I heard . . . really heard . . . things like “risk,” “uterine rupture,” “dead baby,” “brain-damaged baby,” “repeat cesarean,” “VBAC,” and the like.  How did this happen after all I did to ensure that I went against childbirth norms!  Why me?!!!

In the heat of the moment when you’re feeling distressed because pushing isn’t relieving the pain or bringing your baby closer to you, the cesarean can seem like an easy way out.  I pushed for several hours . . . I resisted pushing when waiting for the OB and then waiting for the surgery.  When the OB arrived, she was pretty sure she could help me get the baby out vaginally.  However, she quickly gave up and fairly nonchallantly suggested the cesarean.  I was READY!  Phew, being ‘stuck’ like that sucked, and no one was really helping me get ‘unstuck.’  I didn’t have a doula (because I didn’t think I needed once since I hired a CNM); DH didn’t know any more or less than I.  I was totally relying on the medical providers.

Why do OBs not feel the need when childbirth hits a major roadblock to really explain the consequences of the next step?  I wasn’t in distress.  My baby wasn’t in distress.  The OB could have said, “Now Kimberly, you’ve been such a strong mama through this, but I want to offer you a cesarean as an option.  Before you agree to it, let’s talk about what happens and what impact this decision may have immediately and for future births.”  There was time for this discussion, and it’s not like she was busy with other patients . . . this was 3 or 4 am!

Please care providers, you MUST let us participate in our health care decisions.  We need information before we can make life-altering decisions like these.  When there is time to inform us of the benefits and consequences of interventions, you are ethically obligated to do so.

July 2007 – I became pregnant again, and a couple of gals from my 2004 due date club reminded me about ICAN.  I joined their Yahoo group and dove in.  My eyes were opened and resentment poured into every corner of my existence.  I lost that baby.  I lost the next baby.  I stuck with ICAN, began a local chapter, and brought The Business of Being Born to an indy theatre in town.  I lost another baby.  I found a new doctor who found new things wrong with me.  I struggled for my life.

Summer 2008 – I was going to spend the summer in Denver doing research.  I began looking for a reproductive endocrinologist so that I could get some answers.  Why these chronic losses?  Why this misshapen uterus?  I continued to struggle for my life.  The RE diagnosed what I suspected – really crappy progesterone.  He also believed that the misshapen uterus was not a didelphic uterus but a fibroid.  He wanted to do a laproscopic procedure to remove the fibroid; I insisted on the less invasive hysteroscopy.

He didn’t find a regular fibroid . . . instead he did his best to remove adenomyosis without compromising the integrity of my uterus.  He believed the adenomyosis was caused by the cesarean surgery.

By this time I was pretty disenchanted with traditional obstetrics.  I had been misdiagnosed or refused diagnoses too many times.  I had lost three babies.  I became aware that the cesarean had a negative effect on my ability to have more children.

Current – I hope by now that readers understand that this isn’t about hating cesareans or hating interventions.  Not at all.  What I have ‘hated’ is:

  • Not being asked to participate in my health care decisions ~ How does NOT having women participate in their health care serve mothers and their babies?
  • Being made to feel like ‘one of those’ patients for conducting my own research and presenting contrasting information ~ How does being an oblivious patient help mothers and babies?  How does being an empowered patient hurt mothers and babies?
  • Being denied tests and appropriate treatments that may have helped prevent another heart-wrenching loss 😦
  • Being made to feel like my body just doesn’t work; being taught to be afraid of my body; being taught to not trust my body’s wisdom ~ How does making a woman feel badly about her body and breaking down her trust in the physiologic process of birth help her and her baby?
  • OBs using scare tactics to win compliance ~ Moo??
  • OBs putting their own beliefs about risks (what’s worth it or not) over their patients’ prioritization and contextualization of risk ~ How does putting medico-legal risks above the health (mental, physical, emotion) of the mother-baby dyad help mothers and babies?
  • OBs turning a blind eye to the fact that women may suffer from birth immediately (in the 0-6 week post-partum range) and long term (I was still in acute pain after my last cesarean 1 year post partum); once the ‘healthy’ baby has been ‘managed’ out of the birth canal or uterine incision, it seems as though that’s where their responsibilities end, especially if he or she is not the patient’s regular doctor ~ How does making mothers in the post-partum period low priority patients help mothers and babies?
  • Exaggerating the benefits of intervention and minimizing the risks to the mother-baby dyad ~ How do increased interventions really help mothers and babies?  Are you sure about that??
  • Doctors who aggressively undermine the valid experiences of homebirth midwives and families who choose to birth their babies away from the ‘comfort and safety’ of the hospital campus ~ How ’bout cleaning up your own backyard before you start worrying about mowing someone else’s?  And again, I ask . . . how does tearing down a valid though very different care system serve babies and mothers? 

This.  This is how one very mainstream person becomes a birth activist.  It’s not about hating on specific people but exposing the inadequacies of operating solely in one mindset with regard to health.  The sooner the medical, public health, and alternative care perspectives can truly collaborate, the better health care in the US will be.  This will require a radical shift in thinking and practice, especially from those entrenched in the medical model.

Coda – why an opera singer and music educator should care about birth?  I am of the opinion that the entire body is the vocal instrument.  Impairment of any part of the body can negatively impact the singing voice.  Particularly the trauma done to the lower abdominal region during a cesarean section need to be avoided.  The abdominal complex is the primary source of support for the singing voice.  Interventions and distruptions to this part of the body can have long-lasting negative effects on the singing voice.

Additionally, music gives us the opportunity to engage seemingly unrelated fields.  My dissertation dealt with gender subversion in modern opera.  Really, how different is this than the institutional hegemony of maternal-fetal medicine.  The female body is still a battle ground.

Birth Witness: My Friend’s Amazing Birth

My girlfriend gave me an extraordinary gift last week.  She’s had a complicated pregnancy due to polyhydramnios, and no one thought she’d actually make it to term.  She did!  And I witnessed it!

She and her doctor decided that induction was appropriate.  I certainly wasn’t going to pass judgment on that given all she had been through.  When she went in for induction, her fundal measurement was 48 weeks.  Bless her heart.  Of course I worried about her and hated that I had to be at work while she was being “treated.”  She was induced early in the morning and had her water broken around 2:30pm in the afternoon.  I was concerned about that decision since we all knew the baby wasn’t engaged at all.  That could have caused cord compression and/or prolapse which would have been a quite route to a cesarean. 

Pitocin was of course used to increase her contractions, and at some point, the pain became unmanageable, so she was given an epidural.  I think it was a pretty good epi, because she still had a lot of sensation in her legs and pelvis.

I arrived around 7:30pm to keep her company.  She was quite nauseated, poor thing, because she does not tolerate medicine well.  She had been checked at 7pm and was only 4cm dilated.  I don’t think anyone was very happy with that progress.  However, her nurse was very supportive of my friend’s desire to avoid the cesarean, but of course, since my friend couldn’t really move, the way she was supporting this goal was through medical management – increasing pitocin, increasing the epidural to cope with the pain, flipping my friend side to side (when the baby’s heartrate ‘allowed’). 

We were all very pleasantly surprised when she was about 6 or 6-1/2 by 8:30pm or so.  She was becoming more uncomfortable, and things started to progress much more quickly.  Her hubby called her mom and told her to hurry on her way.

Soon after, my friend started to feel pushy.  It was pretty exciting.  The nurse delayed calling the doctor because she assumed it would still be a while.  (I guess you don’t call the doctor until you’re really sure . . . Her doc wasn’t on call but was still planning on delivering the baby.  Good on him!)

Anyway, lo and behold she started making progress rather quickly, and I swear it was no time before you could see the baby’s head.  It was amazing for me as an observer since when I arrived, she was feeling pretty certain that the baby wasn’t making adequate progress.  And it’s not like anything active other than medical management was being done for her to encourage the baby to engage. 

At some point the nurse told her to stop pushing.  Yeah right.  As soon as the nurse left to call the doc, I told her to go ahead and push.  There were plenty of people around there who can catch your baby.  So she went on about her business.  I was surprised that she was purple pushing (pushing to counts of 10), but it seemed like she wanted someone to count, so that’s what was done.

The doctor arrived and told her to slow down.  I didn’t get how wise that was at that particular moment.  But he told her, and I’ll remember this, “let it build, and then push when you can’t resist.”  All in all, I think she pushed for about 45 minutes, and she only needed 2 stitches.  Because he was encouraging her to control her pushing, she didn’t tear badly.

The baby emerged – first the head, of course.  I left my position by my friend’s head, grabbed the family’s camera, and started taking pictures.  I don’t know if she’ll appreciate having pictures of a baby sicking out of her vagina, but man, it was the most beautiful thing I had ever seen in my life.  It seemed like the shoulders were a bit sticky, but they freed eventually, and the rest of the baby slid out easily.  A beautiful big cord hung from my friend’s body.  The baby had a huge conehead – the head really had to mould to get through my friend’s pelvis.

The baby took a while to come around.  I was distressed that they weren’t bringing the baby over to my friend very quickly.  It seemed like they were doing a LOT of unnecessary stuff.  My friend kept asking for him.  I’m not sure she even got to see him for 15 minutes or so.  Ick.

Stage 3 of labor was over-managed, in my opinion.  The OB applied traction to the cord.  An enormous placenta came out.  It was impressive!!  The OB then began externally massaging my friend’s uterus.  I don’t recall what else was done to/for her.  I was more focused on her emotional state and the baby. 

We were all amazed to discover that the baby was 9lbs and 15.4 oz!  No wonder the baby’s head was so pointy.  I am so glad the doctor encouraged my friend to adjust her pushing strategy.  In the end she only needed 2 stitches!  Amazing.  With the cone, the baby measured 24 inches long.  He was so beautiful.

Mom and baby were finally united, and he was latching on within minutes.  I left soon after to give the family some private time to bond.  I had a hard time going to sleep I was so “high.”  I figured I’d be an exhausted puddle of a woman the next day, but I was still “high” from her birth.

I can’t adequately verbalize how much it meant to me to be there as a witness and as a support person.  I don’t know that she really needed me there, but she knew I needed to be there.  As I write this, I am tearing up.  I’ve never seen or experienced a vaginal birth.  It was such a marvelous thing for me.  And it’s helping me “see” my own upcoming birth.

I’ve studied birth.  I’ve watched movies.  I’ve watch natural birth videos on YouTube.  But there’s nothing like being there in person with a laboring mom.  There’s no substitute for seeing a new person emerge from someone’s body.  And now I am bonded to birth – this experience can’t be taken away from me no matter what happens in the next few months.

You Know You’re a Homebirther When

  1. you find yourself zealously defending the CPM/DEM designation and probably come off as a bit of a wingnut!
  2. you get pissed off just thinking about the horrible things that OBs and nurses (for God’s sake) have said to women who have had to transfer from home to the hospital
  3. you get even more pissed off thinking about the birth that screwed everything up for you (not altogether in a bad way) and your childbearing years
  4. you have this idea to become a doula . . . or worse yet, a homebirth midwife
  5. you have this even crazier idea to leave your day job with full benefits to become a homebirth midwife
  6. you have this even more insane idea to move to Canada or some other country with a better health care system to (a) have your babies and/or (b) become a homebirth midwife
  7. you recognize that malpractice insurance does NOT make birth more safe
  8. you realize that you have to take responsibility for your own choices in pregnancy and in birth – from the Costco dipped icecream extravaganza I ate for dinner tonight (oops, not one of my finer moments) to where you’ll have a baby and with whom and what you’ll allow this person to do for (t0) you as your birth; all of these choices have consequences (hello reflux) . . .
  9. you want everyone to know about homebirth for what it is . . . not what mainstream America assumes it is (been there, done that)
  10. you want families to understand that their choice of careprovider(s) is such an important decision (OB doesn’t mean superior to CNM superior to CPM/DEM; these are very different designations with very different training requirements and very different mindsets; know what you’re getting yourself into!)
  11. you can no longer ignore the voice inside that says . . . “the last thing I want to do is leave my bed and go to the hospital” – I ignored that voice six years ago; now that the option is presenting itself to stay home, I must listen to my inner Truth, pray for God’s blessing and protection, and trust that His Will will be done.

edited to add a point and adjust some “tone”

Supplementing Pregnancy with Progesterone

It amazes me that OBs can still be resistant to testing for progesterone deficiency and treating it.  After two consecutive losses and a clean blood panel, I begged my OB to test my progesterone levels.  I was pregnant again.  Not only did she refuse to test, but she also said that even if I tested low for progesterone, she wouldn’t supplement.  Her “brilliant” idea to treat pregnancy loss was Clomid!  (You can read tons of stories about women taking Clomid and suffering miscarriages as well as being blessed and challenged with multiple gestation issues.)

I lost that baby at 10 weeks gestation.  It died a few weeks earlier.  I was devastated and so angry.  I’m still angry at that nutjob OB.  For numerous reasons I transfered to a more compassionate OB who had been through infertility with his wife and also seemed to enjoy thoughtful discussions with his patients.  Although he misdiagnosed my problem, he supported me in seeking a second opinion with a reproductive endocrinologist (RE).

The RE discovered low low low progesterone.  The RE also found adenomyosis in my uterus that was distorting the shape of my uterus.  He believes that my cesarean caused the adenomyosis.  He removed as much as he could.

I received the all clear to TTC and quickly became pregnant again.  (Becoming pregnant was never my issue.)  I began supplementing with progesterone via 17-hydroxyprogesterone shots.  An early ultrasound discovered that I was carrying twins.  (Recall the one OB’s suggestion to give me Clomid?!??!!!!!!!)

I continued the progesterone injections and weekly progesterone tests during the first trimester of that pregnancy.  My progesterone levels seemed ok on their own, but it was prudent to continue especially since specialists don’t know what a good level of progesterone is for multiple gestation.  After three consecutive losses, I carried my twins to term. 🙂

I accidentally became pregnant during my September 23, 2010 cycle.  I suspected it almost immediately after conception, so I began early testing.  By CD 28 I tested positive for pregnancy.  I contacted my OB’s office (my previous lovely OB died the day he cleared us to TTC in 2008) on a Friday, and was frustrated that it took until the end of the business day on Monday to get a script.  In the meantime, I contacted medical friends and even the RE’s nurse.  I was amazed that she got back to me and was still willing to advise me . . . 2 years later and from out of state.  What a blessing.

Your typical OB isn’t always well-equipped to deal with early pregnancy issues.  My OB recommended 100mg oral progesterone.  I double-checked this with the RE’s nurse, and she did NOT recommend this treatment.  My SIL also told me some sketchy stuff about oral progesterone supplementation.  The RE’s nurse said the best thing to do is either go back on the shots or do 200mg prometrium vaginally.  Since prometrium is so accessible and doesn’t require a stick in the bum, I went that route.  I also want readers to know that it took a while to straighten out the script, but by Tuesday I had what I needed thanks to a lovely independent pharmacist, the RE’s nurse, and the OB’s office following through with exactly what I requested.

I just want to offer this information up for those who are struggling to make sense of their losses.  Really, if you think you suffer from low progesterone and/or a short luteal phase, you need a medical script for progesterone supplementation.  It is unlikely that natural supplements will do the job . . . maybe for marginal progesterone?

Someone on one of my advocacy lists said that taking prometrium vaginally seemed “iffy” to her.  I must admit that irritated me, but she doesn’t know anything about me or how seriously I consider my health decisions.  Had I not been directed to this reproductive endocrinologist in 2008, I would probably not have my twins or be 16 weeks pregnant with my fourth and final baby.

We already feel inadequate

I watched Orgasmic Birth last night on Amazon.  When I told my husband what I was watching, he gave me a look like “oh no, you’re going to be one of those women this time, huh?”  I told him that despite the title, the movie was supposed to be good, and for the most part it was.

If you go to the OG website, you’ll see that they define the word orgasmic differently than you would expect: “Intense or unrestrained excitement or a similar point of intensity or emotional excitement.”  I’d agree that all of the normal physiologic births shown on the video demonstrated intensity.  It’s important to read the definition above with the word “or” in mind.  A woman does not have to achieve orgasm during labor/birth to have an orgasmic birth.

I found it interesting that one of the interviewed NCB experts suggested that we don’t share our birth stories because we don’t want to make other women feel inadequate.  Perhaps a woman who consents to an epidural in a hospital setting will feel inadequate, I don’t know.  But, a woman who has undergone a cesarean after trying to labor will almost always feel inadequate in some way.  (I know there are always women out there who will say different.)  Let me explain.

A woman is told that babies come out of vaginas, and that most of the time that is possible.  Women may enter into the last stages of pregnancy knowing that they want an epidural or to be induced, but they still expect that in most cases, the baby is going to come out normally.  However, most hospital birthers are not given the right kind of support to achieve a natural physiologic birth or normal birth.  Inductions are fairly normal.  Augmentations are fairly normal.  Epidurals are extremely common.  As one expert pointed out on the movie, when most (like 90%) laboring women receive an epidural, and you don’t, you take the staff out of its comfort zone.

So after these interventions and more (constant monitoring, restricted movement in labor, etc.), women are still expected somehow to birth vaginally.  And a third of us are sectioned – or more, depending on the location.  Our bodies failed us, we are lead to believe.  “Thank God I was in the hospital or my baby and I would have been in big trouble.”  Our inadequacies are magnified by the overwhelming successes of the medical machine.

Women who have had cesareans are defensive.  “My cesarean was necessary” is a common belief.  But to suggest that women don’t share their birth stories because they don’t want to make a cesarean mother feel inadequate is not understanding the situation.  We already feel inadequate.

I am 1 of 3 women sectioned in childbirth.

I am one of numerous women told that her body wasn’t capable of birthing her baby.

I am 3 of 4 women sectioned in Montana for twins.

I am nearly 100% of women in my community told they cannot have a VBAC in the hospital after multiple scars.

I am nearly 100% of women told to be thankful that they have a healthy baby after a cesarean section.

Share your birth stories in a supportive, instructive, and hopeful manner.  Give cesarean mamas hope that next time can be different, if she chooses.  And she has to choose; you can’t choose for her.  I myself am preparing for a transformational experience this summer.  I can’t get there unless I embrace stories of uninhibited natural physiologic birth.