Extreme Birth

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The fearless—some say too fearless—new leader of the home-birth movement. By Andrew Goldman Published Mar 22, 2009

On a dreary morning not long ago, Cara Muhlhahn is tooling through Brooklyn in her dented Prius, which she calls her “Mobile On-Call Unit.” Since Muhlhahn is a home-birth midwife, appointments both prenatal and postnatal—and, of course, the big show itself—take place within clients’ homes, and she spends a great deal of her time speeding between boroughs and racking up two grand a year in parking tickets ...

This morning’s first appointment ... is Kristy Bloom ... Bloom is a first-time mother ... in her 38th week of pregnancy. In her first weeks of pregnancy, she’d watched the 2008 Ricki Lake–produced low-budget documentary The Business of Being Born. “I cried through the whole movie,” she says. “And then I was in the bathtub and I had this whole vision of the birth and Cara was there. And I came out of the bath and said, ‘Babe, that woman’s going to be our midwife.’ ”

Since participating in The Business of Being Born ... Muhlhahn has become the most visible proselytizer of the home-birth movement. She just released a memoir called Labor of Love, in which she headily describes her work: “Day after day, I deliver babies, save lives, facilitate and witness near miracles.” ... she’s hoping to grow her home-birth service to handle the increasing demand in New York.

You couldn’t ask for a better home-birth sales pitch than BOBB. The film presents a horrifically plausible portrayal of a hospital childbirth system gone insane, of labor turned into a medical pathology: the continuous fetal heart-rate monitoring that makes it difficult for a mother to get off her back and into a position that actually encourages birth; the fear of lawsuits that compels doctors to perform C-sections on babies experiencing even normal distress during labor; the “failure to progress”—medicalese for laboring in a rentable hospital bed too long—that causes doctors to initiate a chain of “unnecessary interventions” like the artificial-induction hormone pitocin paired with epidural anesthesia, which seem to manufacture their own fetal distress, which in turn produces more C sections ... [which] has done nothing to improve infant- or maternal-mortality statistics.

BOBB didn’t really break news, but it did introduce the natural-birth argument to a new mainstream audience. More than anything else, BOBB de-radicalized home birth, conflating it with garden-variety natural childbirth and allowing Muhlhahn, largely unchallenged, to argue for its safety. There are only two options when it comes to childbirth, the film seems to say, comparing shots of ecstatic mothers hoisting their babies at home with shots of women under bad hospital light screaming for rescue.

Muhlhahn is offered up as the eminently reasonable alternative to the medical mess, shown in her East Village apartment in the predawn hours, tucking her instruments into a doctor’s bag, looking like the medical pro she is, a dean’s-list graduate from Columbia’s School of Nursing ... She looks nothing like the hippie-midwife stereotype. “Downright sexy” is how Ricki Lake has described Muhlhahn, a youthful 51-year-old with low-rise jeans and a husky Debra Winger laugh.

She also doesn’t practice like a typical midwife. Personal experience has led her to dismiss many of what she calls the “myths” that are still taught in school as the bedrock of safe practice. The big babies ... are nothing more than “fit challenges” to Muhlhahn, necessitating only patience. She regularly does vaginal births after C-section at home, and has even home-delivered the riskiest births, breeches and twins ... .... But even more essential than promised nirvana or perfect aesthetics is the implication that messing with the birthing process can affect the bonding between mother and child. In BOBB, French obstetrician and natural-birth pioneer Michel Odent contends that a “complex cocktail of love hormones … create a state of dependency, addiction” between mother and child. Interrupting that natural flow with drugs or a Cesarean, he posits, invites dire consequences. “It’s simple,” he says. “If monkeys give birth by Cesarean section, the mother is not interested in her baby … So you wonder, what about … the future of humanity?”

When you ask Muhlhahn’s many happy customers to recount their birth stories, they struggle a bit; you suspect they feel the way an astronaut might attempting to describe space travel to someone who’s never flown in a plane. “When you get through that transition, and you experience the birth of your child, you get the endorphins, the best bonding experience ... ,” says Jeannie Gaffigan, who delivered her second child with Muhlhahn. ... women turn to Muhlhahn because she inspires confidence in them—confidence in her clinical skills and knowledge of the birth process but also confidence that their bodies are fully capable of the arduous task. Her admirers say that she’s gifted at intuiting when a laboring mother needs cheerleading and hand-holding and when she needs her to step back and leave her to labor in peace ...

But labor is an unpredictable thing, and sometimes the experience is more nightmarish than poetic. Muhlhahn’s patient Sandra Garcia was one week overdue when her water finally broke on a Sunday night in early November. She labored that night and through the next day assisted by her husband, Jeff Wise, and her doula, a former NYU postpartum nurse who was now working for Muhlhahn. (Muhlhahn, busy with another labor, appeared only sporadically.)

Monday night, Garcia was approaching 24 hours of labor. Most hospitals insist that a baby be delivered no more than 24 hours after membrane rupture because of the risk of infection, but Muhlhahn isn’t a big clock-watcher. Instead, she takes precautions to avoid infections: “After rupture,” she says, “no routine exams, no baths, no sex.” By 10 p.m., the doula decided that Garcia was about to deliver. So, with candles lit, Garcia got in the birthing tub, which, because of the risk of infection, represents the endgame, the mother’s pushing venue. Except it wasn’t time to push. At Garcia’s insistence, Muhlhahn performed an exam at around 3:30 a.m. and discovered she was only a half-inch dilated. The doula had somehow misjudged her progression. Still, Muhlhahn wasn’t concerned. “There’s no such thing as stalled labor,” they remember her assuring them. “Labor just takes a long time.” With that, she left to deliver another baby.

Late Wednesday afternoon, nearly 72 hours into his wife’s labor, Wise started to freak out. The doula had gone home to rest. It was getting dark. They had no instrument to check the baby’s heart rate. His wife’s face was pallid, her knees and elbows raw from supporting her weight during the contractions ...

“How long is too long for a woman to be in labor?” Wise demanded to know when Muhlhahn finally returned to the apartment that night. “Never,” Muhlhahn replied flatly. Her philosophy was simple: Trust the wisdom of the body to send the baby out when it’s ready. But she agreed to examine Garcia again. If she hadn’t progressed significantly, they’d go to St. Vincent’s. The results were startling: two centimeters. She had hardly progressed at all.

Garcia crouched on all fours in the back seat of Muhlhahn’s Prius as they drove to the hospital ... The next morning, Garcia woke with a 103-degree fever, a sign of infection ... after 84 hours of labor, she was still less than five centimeters dilated. The baby had to come out by C-section. Remment Garcia Wise weighed in at eight pounds, eleven ounces, about two pounds more than Muhlhahn had estimated. Rem was whisked away to the Neonatal Intensive Care Unit, where he stayed for five days ...

“How do you feel about having a C-section?” Muhlhahn asked the couple at a follow-up appointment to discuss what had happened ... Garcia felt the question was barbed with the implication that if she’d only had more patience—tried harder—she could have had a vaginal birth.

Muhlhahn calls St. Vincent’s her “backup hospital.” About 10 percent of her patients end up transferring there during labor. “St. Vincent’s is her dump,” says one former obstetrics resident ... “She’d bring her patients in, holding their hands, find out we were going to have to do a section, and then she’s out the door.” [In Austrtalia, the mdiwife generally stays with the woman in the case of transfer].

There is, of course, a long-standing animosity between doctors and midwives, particularly those who take births out of hospitals. In a 2008 policy statement, the American College of Obstetricians and Gynecologists reiterated its position against home birth: “Childbirth decisions should not be dictated or influenced by what’s fashionable, trendy, or the latest cause célèbre.” But St. Vincent’s seems to have bridged the divide better than most hospitals. George Mussalli, the chairman of obstetrics and gynecology since 2006, has fostered much goodwill within the midwifery community. ... JJB Midwifery actually have hospital privileges there. .... For all her home-birth successes—she has delivered more than 700 babies—Muhlhahn has also had some tragedies. In 2003, she and her former birthing center settled a $950,000 malpractice suit brought by the parents of a child who was injured during delivery. As the baby’s head was crowning, he suffered a shoulder dystocia, when a baby’s shoulders get stuck behind the mother’s pelvis. It was imperative to get the baby out quickly, because he couldn’t breathe in that position ... The child survived, but the cervical nerves in his neck were damaged, rendering his right arm paralyzed, a condition called Erb’s Palsy ... Garcia’s complaint argued that Muhlhahn should have known that the baby would be too large for a vaginal delivery. [There's no way of knowing with certainty if a baby will fit or not. Shoulder dystocia can happen at home or in hospital; some would argue that it's more likely in hospital because women are usually restricted to birthing on their back]. ....

The panel’s star, however, might be Jessica Robinson, who receives gasps from the impressed crowd for revealing a thumbnail of her experience: 76 hours of labor, which included a 30-block walk on her third day and an episode in which Muhlhahn had to coax her out of the bathroom of a Brooklyn acupuncturist’s office. The adventure eventually yielded a ten-pound, twelve-ounce boy, the heaviest baby Muhlhahn had ever delivered to a primip. “It just seemed,” Muhlhahn says, savoring the victory, “like a completely normal delivery.”

Melissa Maimann, Essential Birth Consulting.