Certified Nurse Midwife, Sarah Waldron

[00:01] Michelle: Sarah Waldron is a Women's Health Nurse Practitioner and a Certified Nurse Midwife who started out in high school, volunteering in labor and delivery, was pulled into a room to watch a birth, and was hooked!  After becoming a nurse, her path to midwifery was not linear. Along the way, she worked in med surge and pediatric emergency care. But her experience in these different areas of nursing has been invaluable in her work as a midwife. After many successful home births, Sarah opened her own practice, Wildflower Birth and Wellness. She addressed my safety fears head-on. As a NICU nurse, I was initially skeptical about home birthing, but Sarah's matter-of-fact approach, passionate confidence, and ability to uptriage when necessary took the fear out of the process. And then there's the topic of breastfeeding. Sarah was actually breastfeeding her newborn during the interview, YAY! Her patients meet with an IBCLC before giving birth to ensure they have all the information and support they need. I really appreciate Sarah's comprehensive and holistic approach to patient care. Her dedication to her patients is clear, and her passion for her work shines through. In the five-minute snippet: are these clothes multiplying? Here is Sarah Waldron. Well, good morning, Sarah. Welcome to the podcast.
[01:47] Sarah: Good morning, Michelle.
[01:50]: It's so great to have you. We met on Instagram through my sister-in-law Liz Patty. And when I put out my I need a nurse midwife, she immediately responded within like a minute. And I think she didn't tag you, but she said, I have someone in mind. Let me see if she's interested. And so that's how kind of everything came to be. So I'm really happy that all that happened.
[02:19] Sarah: Yeah. What a small world that Liz and I went to nursing school together and then we were looking for someone.
[02:28]: Yeah, it truly is. And I've said this before, Instagram is such a great community to connect with people. So let's just get started because you have a very interesting path to being a midwife. So talk about that.
[02:46] Sarah: Yeah. I initially wanted to work in women's health in some sort of capacity. I kind of figured this out in high school, I was interested in going into healthcare, and our local community hospital in the small Northern California town that I went to high school in had a volunteer program, and I was able to volunteer in labor and delivery as mostly just a clerical volunteer. I helped put together birth kits. I helped kind of file paperwork, kind of nothing to do with the clinical side, but I was still really excited to be in that space. And a friend of mine that I went to high school with, actually her mom was a labor and delivery nurse at the time, and one of the days she was working. She had a patient, and she asked if I wanted to see the birth. And I was kind of taken aback because I'm this young high schooler and this mom had kind of offered that to me. And so I remember walking into the room and staying very close to the door. And the physician that was there actually encouraged me to move a little closer. And beforehand, my friend's mom, who was her primary nurse, had said, you're either going to want to cry, pass out, or throw up. And I was like, oh boy, two of those sound really bad and embarrassing to do. Crying I can handle, but the other two sound not so great to do in front of people. And so I was a little nervous, but I obviously cried. I did not pass out and I did not throw up because I was just in awe of it. And I was like, okay, I want to watch babies be born. That's what I want to do. I want to help with that. And so that kind of started my nursing class. And I graduated high school and got into UC Irvine. And UC Irvine's nursing school structure is a little different. You get in right as a freshman. And so even though the first two years are prerequisites, you're in nursing school right away. And so you orient and you get to meet all of your other classmates. And so that was really cool to meet some of the people that I'm still friends with nowadays and to just be on that path together. So fast forward through my first two years of prerequisites, which were obviously not my favorite part because there were lots of very big, intimidating science classes. But we started the actual nursing classes and I was really elated to be at that point because they were smaller, they were more intimate, and they were finally what we know striving to do. I had a professor, Thuli Rousseau is her name, who is a midwife. She's much more than that. She's all kinds of powerhouse things. But she was teaching her nursing research class and I wanted to do a paper on vaginal birth versus cesarean and kind of express my interest in that. And we chatted and she told me, before you pick your topic, I want you to go home and watch this documentary. Okay, which documentary? I want you to watch the Business of Being Born. And I was like, okay, I've never heard of it, but sure. And my whole life path quite literally changed after watching that. In 2 hours, my whole life changed by watching that documentary because my eyes were kind of open to what I actually wanted to do without knowing that it was a thing. And I got to see midwives and I got to see out-of-hospital birth and kind of how the whole spectrum of birth kind of pans out. And so I remember calling my now husband and my parents, and blabbering about how I was going to catch babies in bathtubs and I was going to have my own babies at home, and I was going to do all these things and they were like, what's a midwife? What are you talking about? And I immediately began looking into midwives and midwifery and birth centers and home birth and all these things. And I was afforded a really great opportunity at a birth center to again start volunteering, get my foot in the door, kind of just help with paperwork, help with birth kits, this kind of stuff. And then I eventually, after a period of time, was asked if I wanted to start attending birth as kind of like the second unpaid observer to kind of help with whatever was needed. And I remember the first home birth I attended like it was yesterday. I had only seen hospital births at this point, and I had only seen, I want to say, medicated births too. And so I go to this home birth and this mom is laboring hard, really working hard. She's got her eyes closed, she's making lots of noises. And I was just in awe of her. And then her not tiny baby, I think he was like eleven pounds, he was born just immediately was alert and awake and crying and holding her baby and just this palpable energy shift in the room. It was just fascinating. I was just in utter awe of the whole process and how her determination and hard work and kind of from the outside observer, her pain and seemingly kind of suffering turned into this beautiful immediate shift as soon as the baby was born. After attending hundreds of unmedicated births, now I kind of have a much more in-tune sense of discomfort versus true suffering. And so now I realized she was definitely not suffering at all, but it was just amazing. And so at that point, not even done with nursing school yet, I was kind of like, I just want to go straight to midwifery school. I don't even want to work as a nurse. I just want to go straight into doing this. And that is not how my life panned out. But it worked out exactly as it needed to. I was able to finish nursing school, and I did my intensive in labor and delivery at a more high-risk hospital, which was also very different. It was really kind of these two completely different worlds. I home birth and birth center assisted on the side for fun at the birth center. And then I would go to clinical and I would see these really high-risk cases. And for me, it just showed the two appropriate places where birth can happen. I think for some people that doesn't always kind of connect. They see the high-risk stuff and they're like, oh my gosh, how could anybody give birth without all these tools and resources? But I feel like having seen such a contest at the same time, it just was more apparent to me that some people are low risk and they can birth out of the hospital safely, and these other people who have these conditions really need the hospital system that we're lucky enough to have. So I think that that perspective was really helpful. But as I graduated and took my boards and became a nurse, there was a part of me that was like, okay, you've spent this time and this effort and you've learned all these skills. Let's kind of put them to use. And so I actually got a new grad job in Santa Barbara at the teaching hospital there in MedSurg. It was a pulmonary, renal, and infectious disease floor. It was what I had told myself would be the last thing I would want to do, but it in the moment was really hard, and it was like, oh, I really want to still be doing birth. And I also found a birth center there to work at, which was really nourishing for my soul, but it was a really good experience. I dealt with a lot of different infectious disease cases. There were people who had ostomies. There were people with chronic liver failure. I dealt with this wide variety of things, and I got to take care of a lot of people who were nearing or at their end of life, which I think helped with the different perspective of being at the beginning of someone's life. We got to take care of people who had lots of family who were there to support them and other people who didn't have any family, and so we were their family. Towards the end, I think it was really important for me to be able to experience that, even though at the moment it didn't feel that way. Hindsight is always 2020, of course, but I continued to do birth work through the local birth center, and again, at that point weighed my options in terms of what type of midwife I wanted to eventually be because that was still my goal. When we moved to Santa Barbara, that was my first time experiencing non-nurse midwives. So they had both nurse midwives and certified professional licensed midwives at their birth center. And so that was my first exposure to kind of like, oh, there's midwives that are coming from a whole different background. They're not nurses. First, they're doulas or they're lactation advocators or some other birth world that they've lived in, and then they become midwives and kind of learned more about their training and process and realized that there was a whole kind of more holistic, some people would say crunchy part of birth and midwifery. And I was kind of alert by that too, and was really grateful to be able to see that as well. And as time passed, I kind of got more serious about, what do I need? What's my checklist to get into midwifery school? And one of the big ones is labor and delivery experience in hospital, which for nurse midwife programs, that is the kind of baseline requirement is that you have to have labor and delivery experience. So knowing this, I had had another friend from nursing school that Liz and I went to school with who worked at a hospital back down here in Orange County, and he kind of had said, like, we're hiring, let me talk to my manager. And I got pretty quickly a job in labor and delivery. And I had sat down with my now husband and my parents. And actually, at the time, I think my husband and I were already married. Yes, we were. And they all kind of said, it's going to be a lot different than this out-of-hospital birth stuff you've been doing. Are you sure you want to do it? And I kind of said, I don't really have an option because this midwifery experience I have, even though it's with midwives directly, doesn't count for grad school. It seemed silly at the time, and it still seems a little silly that years of midwifery experience alongside midwives still wasn't a good enough qualifier for a program. Yeah. Even though in hospital labor and delivery experience is very valuable, and you obviously get a higher volume of what you're seeing, more variety in what you're seeing. I didn't have to have any midwifery experience. The requirement really was just six months currently working for a minimum of six months, or a previous one year of experience in labor delivery. They didn't care if we had any experience working with a midwife or had never worked with a midwife. And that, to me, seems like, I don't know, you're choosing this life path, you're getting this advanced education in something, and you don't even have to have worked alongside someone who has that same title. Seems kind of silly to me. I worked my year in labor and delivery. It was hard. It was hard and also really helped in a lot of ways. I got to see people who planned for a certain birth, and they ended up with a completely different experience. I got to support people through their plans and all the way to the end, we got to see people who experienced losses and who had unknown pregnancies, who would come in labor. And so I really did get to see a whole gamut of things while I was there. And while working there, we got pregnant with our first daughter, who's now six. She'll be six and a half in October. And I kind of went against the grain. I wanted to have a midwife-supported birth. I wanted to birth out of hospital. I was pretty vocal about that with my coworkers. I didn't kind of feel the need to pretend I wasn't doing it. And it was an interesting reception from the people I work with. I think some people were totally fascinated and they really wanted to know more about it. And then other people who had maybe been in the game for a long time kind of were like, Why would you want to do that? And, yeah, at the end of the day, I just kind of felt like this is just an opportunity to either educate someone who doesn't know or to have a discussion about it. But I wasn't there to convince anyone of anything. I didn't feel like I needed to be convinced of anything. But we had our daughter at a birth center, and we had a water birth with her, and it was an amazing experience. And I had made a joke at the early stages of labor with her. To my husband, I said, oh, this is definitely why people go into the hospital and would want an epidural at this point. Because if you're not ready to feel a lot of these sensations and you don't have someone who is there saying, like, no, you've got it. We've prepared. Use your techniques. I can absolutely see why someone would want to be more comfortable with the process of labor. And we were postpartum with her, and I kind of remember saying, I don't think I can go back to working in the hospital doing birth. I just don't know. And I'm having a hard time kind of wrapping my head around it. And my husband had made the suggestion to do something unrelated to birth. He said, Why don't you go work in an emergency room? And I laughed because I was like, that's a whole world different. What are you talking about? And he kind of said, before you really apply to grad school and spend the time and the effort and the money, maybe take a break and see if that's for sure what you want to do. So I interviewed for a job at a local pediatric hospital, seven weeks postpartum. I went to the interview, which is crazy to think about now because I'm like, ten weeks postpartum with this one, and I'm like, I can't even imagine. But, yeah, I went at seven weeks postpartum and interviewed, and I got the job and started closer to that twelve to 16-week mark because it actually timed out perfectly for when I would have been going back to work anyway. And it was a totally different experience. It was not just an ER, it was a pediatric ER. And I loved it very much. It was apparent within my first week there that this was the type of physician dynamic that I appreciated. My coworkers were really great in all of the jobs I've had, and so it was nice to be back in a place where I had coworkers that I could, I don't know, just spend time with that really got it. As a parent, there were a lot of people who had kids too, so it was nice to kind of have their support going back to work as a mom. And about six months into working there, another friend of mine that I had worked labor and delivery with at the other hospital had said, hey, I'm going to apply to midwifery school. I know you want to go, why don't you just apply with me? I was like, oh, I don't know if I'm ready yet. My list is a little still. And she was like, well, it wouldn't start for a whole year. You can always say no. And I was like, okay, fine, I'll apply with you. And by the time I applied and got to the interview date for a spot in the program, I was like, okay, no, if I get in, I definitely want to go back. And so I started midwifery school when my first was about 18 months old and I made the decision to stay working in the pediatric ER while I was in school. And I home-birth assisted some midwives on the side for fun to kind of keep those skills up and, yeah, went full force into grad school. The program I did has a part-time and a full-time option. And so I did part-time so that the first year was kind of split up into two years. And then the last year was more intensive for clinical, which is funny because the last year was 2019 to 2020 and then kind of finishing in 2021. And so COVID was another fun thing to deal with while in grad school like that. Yeah, I really enjoyed being back in school. I think in the years following graduating undergrad, I was kind of like, oh my gosh, I'm never going to go back to school. I have a career, I don't need to go back to school. And then nursing has shifted so much in the past decade where really being a bedside nurse isn't everybody's long-term goal anymore. I think I was right at the edge. We graduated in 2013 from UCI and we were right at the start of the conversation of like, you can come back and you can become an NP and you can do education and there are other fields in nursing that you can do sooner than waiting after you've been a bedside nurse for 1520 years. Because I think that's kind of where the path was laid out for all of the places we did our clinicals and the nurses we knew is you were a bedside nurse for 15 or 20 years, and then you became an educator, or you were a bedside nurse for 15 or 20 years, and then maybe you became an NP. But we were that first kind of tipping point of like, no, you can go work for a year or two and then you can become an NP. But it was kind of very fresh for us and so taking that break from school was nice, but going back it was kind of fun. Overwhelming with a little one at home, but fun at the same time. During my program, I worked at the pediatric hospital, which was nice because when I was at work, I just got to have my work brain on. And then when I was doing schoolwork and at the start of clinicals that was my midwifery brain I got to put on so they didn't cross paths too much, which was kind of nice for my compartmentalization in my brain. And yeah, then I graduated midwifery school and I knew that I wanted to do out-of-hospital work. And so I had been fortunate enough in school to do clinicals at a freestanding birth center for most of my rotation. And then I went and worked at a birth center for six months after graduation and caught lots of babies there and then decided to open my own practice. We knew we wanted to start trying for another baby. And the birth center I had worked at was 45 minutes on a good day from our house. So I kind of wanted to be closer to home and have more control over how far I was traveling. So, yeah, that's where we're at now, I have my own home birth practice and I do in-home prenatal care, labor and birth care, postpartum care, and I also do wellness and GYN care as well.
[23:15]: Wow, Sarah, that is quite a journey. I mean, there's so much to unpack. One of the things that immediately kind of caught my attention was when you were talking about your desire to be a midwife, you knew that you had this conviction and then having to work in labor and delivery and I totally get it because that's where you learn so many basic skills, right? VAG exams, monitoring positions. But then I kind of was thinking, that's sad because then you're sort of indoctrinated, I guess into the way that we do things in the hospital, which is so different than what you're doing.
[24:10] Sarah: Yeah, absolutely.
[24:14]: I get the reason why. Because you get a lot of experience and like you said, you get the volume, so you just learn so much faster and going to all those deliveries and C sections and resuscitations and it gives you a really good basis for what you're doing now. But I'm the kind of one that do what you want to do and you shouldn't have to wait to do what you want to, you know, you shouldn't have to do the typical where they say you need one to two years of med surge before you can do what you really want to know.
[24:52] Sarah: And again, it's so different now. I am on the alumni board for UCI's nursing program now, and so I get to help kind of with their entry levels, master's program students and the undergrad students. And it is an entirely different world now. They are all getting hired into specialties as new grads. They're not doing years of Med-Surg first. They're getting to go into the NICU and the ER and to labor and delivery, and they get to be really good at it. As I said, there's definitely value in working Med Surg first. There's the value in, I think, more so there's a value in variety, depending on what you want to do, though, if someone knows they want to be a NICU nurse, there isn't tons of value necessarily outside of going straight into NICU, if that's what you want to do. That is a super specific subspecialty of care with teeny tiny babies. And so taking care of older end-of-life patients doesn't necessarily help with the specifics. I think it helps with being a human, I guess. I don't know, the human part of us as nurses, I think it's good to care for a variety of ages, but I don't know, it's a different world now, and they're not doing the same kind of you have to do this thing first.
[26:22]: Yeah, I was really happy to see that. The last couple of years that I worked in the NICU, we were hiring a lot of new grads, and we just had a manager that kind of was thinking outside the box and saying, let's get them from the start so that they can learn all these skills and just be the best NICU nurses. Because they had the conviction, like you did, that, I know this is what I want to do. I don't want to do anything else. So let's take that passion and that energy and feed it.
[27:01] Sarah: Exactly. I had the same experience in the emergency room. They were hiring a lot of new grads. And there is there's a different level of it's kind of like that wide-eyed go-get-it attitude that you have right when you start your nursing career. And I think that that is helpful when you're doing something that's so specialized.
[27:27]: Yeah, I agree. Well, okay, so let's take where you are now. So now you have your own practice as a midwife, and you are a WHNP. And so talk about your scope for a moment. Just kind of,  what can you do within your scope as a nurse practitioner and a midwife?
[27:49] Sarah: Yeah. So as a midwife and a women's health nurse practitioner, a variety of things. And it's interesting because my midwifery license and certification encompasses everything that the NP side does, too. So it is interesting that there is a dual program, and I get licensed dually because there's more I can do as a midwife than I can do as an NP because I can obviously touch babies and do comprehensive postpartum care and all that kind of management of the perinatal period. But then as a women's health NP, I kind of get more of a scope of a variety of different women's health things. There's the fertility side of things. There's preconception, there's GYN care, there's perimenopausal care. There's a whole variety of things that happen outside of pregnancy and birth that our bodies go through that can be supported through the NP role. And so the combination of the two kind of gives me the ability to care, really, across the whole spectrum, even in terms of as soon as someone gets their first period and they enter into that rite of passage. All the way till the end when they get their last period. And then they're entering into a whole different rite of passage with birth in the in-between. So I can do clinical pap smears and blood work and interpretation of those things, preconception blood work and basic hormone assessment and evaluation, and then the pregnancy, birth and postpartum care, and then perimenopausal care in terms of those. Type of hormone shifts and management of that on a basic level, and I say basic level for all that because there are more specialized providers out there in all of those realms. Fertility on a basic level. If I'm seeing something that needs more support, we're really lucky that we have reproductive endocrinologists who are available to do more intensive support. Same with perimenopausal care. If someone's experiencing some things, there's the assessment of it, but then the management with hormones or medication can be managed by someone with more training and experience if that makes sense. Technically speaking, yes, my scope covers it, but at the same time, I know my own clinical limitations. And so we're really lucky to have providers who specialize in that type of work. It's kind of like the family nurse practitioner program. They can cover all kinds of things and you can do subspecialties, kind of the women's health is the same way. There's a lot of subcategories in what that means.
[30:53]: Yeah, it sounds like you have a really wide scope. And part of that, obviously, being a nurse practitioner, is you have the ability to prescribe. And there's been a ton of buzz about the FDA approval of the new medication Zaranolone. So what are your thoughts on that? That's for postpartum depression. What do you think about it?
[31:19] Sarah: Interesting. I have thoughts because I'm also relatively still freshly postpartum in my own experience. And I saw that news come out. I had experienced postpartum depression anxiety, pretty mild on the spectrum, having seen again the variety of that experience for people. However I did have postpartum anxiety and depression with my first, and it took me really three years to come out of the fog of considering having another baby because it was so rough for me, not just mentally. I also had a thyroid condition and subsequent inflammation that caused full-body hives for a long time. And so for me, I kind of was like, all right, how can I best prepare for the next time? What can I do pre-conception? What can I do in my pregnancy? So that the second I am postpartum, I have enough nourishment, enough support, enough rest, like, what do I need to do to prepare for that? And so when I saw the news of the medication come out, my first thought is that it's great that it's specific for postpartum anxiety and depression because there's not a lot in our current healthcare model that specifies for women, let alone postpartum, right. Things traditionally have tended to be based off of the male body and what the response is there. And so to have something specific for that is great. But I do think that as a more holistic practitioner and my background having included so much nonpharmacologic intervention, it really, I hope, doesn't get used as an excuse to still not improve what we have for birthing families. Because at the end of the day, the prevalence of postpartum depression and anxiety is not because we're lacking a medication to quote-unquote, fix it. We do not have enough support for families. There's not enough education on nutrient density and how to nourish your body while you're pregnant so that you can set yourself up for a good postpartum. There's a big gap in postpartum care, I think specifically postpartum care from providers because of insurance. If you have a run-of-the-mill birth with a provider, whether it's a midwife or an OB/GYN in the hospital that's covered by your insurance, you're only allowed to have two postpartum visits that are billed in the global package. And outside of that, you'd have to bill differently for any extra visits. And because of that, basic support visits that don't have a specific need. Like, of course, if you're having infection symptoms, of course, if you're having depression symptoms, those all can be filled appropriately. But if you are fine and you just want more support or peace of mind or encouragement or whatever from your provider, that doesn't exist in that insurance-covered world. And so my initial thought when I saw the medication was just kind of like, man, I hope that this doesn't get overprescribed without looking at the big picture for people, because that tends to be how our pharmacologic system works anyway. Like, oh, you have high cholesterol. Let's put you there for that, instead of addressing your diet and your exercise and your stress management and your family history. That was my first thought, was kind of like, oh gosh, I really hope that this doesn't become an over-prescription issue. And then the other side of the coin is I was looking at the side effects from it, and one of the side effects is like, suicidal thoughts.
[35:40]: Sure.
[35:41] Sarah: And I was like, well, that's tricky because if you're feeling depressed and you have postpartum depression and you're already not getting very much sleep, you can have sometimes very fleeting intrusive thoughts and other times very persistent intrusive thoughts. And so for me, the idea that a medication that should be helping with depression can potentially be causing those thoughts is a little worrisome because again, the support system is the person who's prescribing that medication. Going to really go over all those details and then say, if you have these thoughts at three in the morning, here's who you need to call. Because as the postpartum middle of the night tends to be the time when all the thoughts happen anyways when you're just a little delusional and half asleep. But then at the same time, it's nice that for those that do need medication management, they've done all the things. And of course, we all know that supportive things can only go so far and sometimes it's not enough. I'm glad that there's something that's being specifically addressed for that, but yeah, lots of thoughts and feelings on it.
[37:03]: Yeah. I echo those sentiments because I think in our society we do rely on medications for so many things that could be moderated with other interventions, like you said. So yeah, I wish the same that it's not just a quick fix, but that we address those other issues.
[37:25] Sarah: Yeah.
[37:26]: And I was reading that some health insurance companies don't cover midwifery services. Yeah, I was really shocked about that.
[37:35] Sarah: Specifically out of the hospital. I think it's getting more traction to get at least partial coverage. I think during COVID people were having even more luck getting it covered because they were saying like, oh, well, my COVID risk is going to be higher in the hospital, so I'm choosing to have a midwife at home. So you need to cover it because you can't offer me the same level of protection against COVID. People would kind of use that to their advantage.
[38:01]: Sort of like working.
[38:02] Sarah: Exactly. But yeah, outside of that it's not always covered.
[38:11]: What do you think the reasoning is behind that move? Is it liability or where do you think they're going with it?
[38:19] Sarah: I mean, the more cynical side of me that doesn't think insurance coverage is always in the best interest of patients is because it's a lot cheaper to have a home birth with a midwife, just from the logistics of how much something costs. I think the average vaginal birth in a hospital with little to no intervention is still like $25,000, but the insurance will cover lots of that and so people often only have to pay $1,000 of it or something right. Versus at home, my whole entire package is $8,500. And so of course that sounds like a lot of money out of pocket, but in the scheme of how much a hospital birth costs, it's not as much money. And so I think there's some level of like the insurance companies know they're not going to make as much off of it as they would otherwise.
[39:21]: I see that cynical side coming through. Yeah. And I kind of share that cynicism because we honestly have a for-profit system right now and it's more a disease care than health care. So, yeah, I share that. Do you care for the baby at all, Sarah at birth? And then do you have any part, like in the immediate postpartum period?
[39:50] Sarah: Yes, at the birth, the midwife is still, and this varies out of the hospital versus in the hospital. But out of the hospital, they are both my patients, the birther, and the baby. Right. The two B's are both my patients. And that's through the immediate postpartum period. And then I also have scope to cover the newborn in the 1st 28 days. Some difference between nurse midwives and professional midwives is I believe that professional midwives have a longer scope that covers newborns versus the scope that nurse midwives have.
[40:32]: Well, let's talk about home births for a second since you touched on that and your experience in your own home birth. And I know you've attended a lot of them, and I'm going to look at it from what I've always known is working in a hospital, maternal child health. NICU and so being an adamant nurse for many years, I attended many vaginal births, many, many C sections, and it was a super fun part of my job. I really liked going to birth because each one was so different. And I particularly liked going to the midwife births because they was just one for our hospital. We had OBGYN, we didn't have any nurse practitioners, and we had one midwife, which I think was criminal for a hospital that did 4500. And it wasn't until just before I left that we got two more midwives. And same thing with doulas. We had a couple of doulas and a really busy labor and delivery. But the home birth, so we look at it from a perspective of, like, we only see the disasters, right. Because we're working in a hospital, so we're the ones that are receiving the baby or the mom from the home when something's gone wrong. I know you've worked with professionals that are like, no way would I ever do it. I would never advise for anyone in my family to do it. It's like that nurse curse. Something is going to go wrong. So how do you approach that? And I would assume that in your own practice, you're not trying to convince anybody because those people are coming to you because they have information and they want to do a home.
[42:43] Sarah: Exactly. Yeah.
[42:45]: How do you approach people that are like, no way, it's totally unsafe? Do you throw evidence at them? Do you just let them be in their own negative state? How do you approach that?
[42:58] Sarah: Yeah, I mean, it's kind of multifaceted. Like you said, people who are coming to me are already at least interested in understanding of homebirths. I've had a couple of people who end up consulting and not really like either the partner or there's some level of discomfort, and they don't usually move forward. But in terms of the whole thing. I kind of had explained it because I had talked to one of the doctors I worked with in the ER because they said we were talking about home birth and midwifery, and they were just like, I don't understand. We always see these kinds of train wreck babies, and I'm like, well, yes, when they come here, of course, they need help, but that's 1% to 3% of the birth. Of course, you're not seeing the perfectly healthy babies because they didn't need you. You're also not seeing the kids who are fine because they didn't need to come here. That doesn't mean that kids aren't okay. I think the comparison for me is just there's a sense of uptriage in every type of health care, right? Like, For someone who comes to the ER with an infection that got managed or urgent care, and now they need more, and they go to Med Surg first, and then they end up needing more, and they go to the ICU. There's not this level of judgment based on previous treatment if that makes sense. Like, you're just up triaging. That's what the ICU is there for. What they're there for. They're there for when you now need a higher level of care. And I think there's this misconception and misunderstanding about the birth world where that's not viewed the same way. They're not viewing that the midwife bringing in someone for whatever management, right? Decreased fetal heart tones and labor, postpartum hemorrhage, postpartum newborn airway help, these are all things that have been acknowledged as no longer able to be taken care of where we are. And so we're up triaging, we're increasing the level of care we need. And instead of that being viewed as like, okay, great. You were managing fine until something happened, and now you're here because you need us, and that's great. That's what we're here for. It's kind of this like, oh, my gosh, well, this is why you shouldn't have been at home in the first place. And it's kind of this judgment where they're not seeing the 97% to 100% of the other totally normal safe births that happen in our practices because they're not seeing it. It's just like, they don't see every person diagnosed with a disease because they get managed just fine without coming in, but it's not kind of viewed the same way, and it's because it's not a disease process. I think that's what's tricky is, traditionally speaking, birth was never medicalized the way that we have medicalized it in the past several decades. Like, birth was a normal process. People have been having babies since the existence of humans, and they're going to keep having babies through whatever type of changes we make in our healthcare system. And traditional support of that is not this New Age bad. It's just kind of people choosing to go more with, I don't know, with roots or wanting less intervention. And so it's tricky because you're right when you're in the hospital, especially if you have a baby who needs the NICU, especially who was born at home, there is, of course, this kind of thought process of like, oh, well, we could have avoided this. But I think in a lot of ways, a lot of my training and a lot of my process that I talk to all my clients about is like a threshold, a tolerance for what is normal and a threshold for what is not. And I would always rather use the resources around us, whether that's transferring for labor and delivery, transferring for postpartum, or transferring for baby. I want to use those resources before we get to a point where it is chaotic for the receiving end for the parents and for me because that's what that up triage is about. But again, it's not necessarily my job to convince anyone of anything, right? I'm never going to convince someone about what I feel safe with or what someone else feels safe with. All I can do is educate. And there are a lot of people in healthcare who tend to be very research-based and what the evidence says, and there is a lot of research and evidence that supports low-risk birthing families choosing to have out-of-hospital birth is not an unsafe option. Of course, it would be unsafe if we have the same type of interventive scope that you have in the hospital. Of course, it would be unsafe to give someone pitocin and labor at home, right? For a midwife, at least, there are several home birth OB's who have that higher level of scope and higher level of management skill at home. And so there are even some OB's who will do at home medication management that midwives don't do. But I think that's the thing. There's a lack of witnessing physiologic birth that makes the idea of home birth seem, for lack of a better word, crazy for some people. Because of course, the birth that you're seeing in the hospital would be crazy at home. I'm in agreement to that. All of these medicated interventive births wouldn't be great to have at home. I don't disagree with that. But they're not seeing true physiologic birth in the hospital. They're just not. Because even the hospitals that offer a more physiologic approach still have policies and procedures that begin to slowly decrease the physiologic aspect of things and slowly increase the risk. So I think they're just two different worlds. It's like comparing two different sporting events or two different types of cars or something. They're just different. Even though the roots are kind of the same, they're just very different. Yeah.
[49:38]: And when I was thinking about this, I was looking at it obviously from my perspective, and I was saying, Michelle, you haven't seen 200 successful home births. You've seen 200 C-sections where you needed a lot of resuscitation and intervention, and the baby had to come to the NICU and the mom had birth trauma. And so this is what you've been exposed to and you haven't been exposed to that physiological birth, like you said. And I think if we had that kind of training, we would think a lot differently about it.
[50:25] Sarah: And that would be my goal in life, is for providers and nurses and just people who work in birth to see physiologic birth. And I think there's other healthcare systems outside of our country who manage birth very differently because they haven't strayed as far from traditional they in the UK. Midwives take care of everyone until they need an OB. And it's not the other way around. It's not people seeking OB'S immediately and then finding out about midwives. It's standard for everyone to see a midwife and then once you've again reached the threshold and you now need to be up triaged, as I kind of like to say. Now you go to the OB, now you go to the specialist, now there's a different plan, but it's tricky when.
[51:20]: Yeah,  we have it backward.
[51:22] Sarah: Yeah, we're running it a little. Exactly. And I think, too, there's this on a much deeper level, there's just a lot of fear around birth that I think is very deeply tied to the same fear as a society we have about death and the same fear of illness. There's just kind of a lot of fear around physiologic processes that people don't know how to, I don't know, support. Because I don't want to say the fear is bad. It's more so just what do you do with it and how do you support it and how as a provider, if you hold that fear, how do you support people who think differently than you? I saw this thing circulating on Instagram the other day that I don't know where the OB practice was at us, but it was a sign in an OB's office that said, we are no. Like, please let the office staff know if you have a doula. Because Dr. So and So does not work with lay labor support people, because by not doing so, it creates a deeper relationship with a doctor. And I literally snorted at it because I'm like, what deeper relationship? Does this OB give you their cell phone number and tell you to call them at two in the morning? Does this OB see you for an hour and a half every visit? Does this OB see you six times postpartum? Does this OB come in early labor to support you? Like, no. The answer is no to all those things, because it's just not how our system is set up. That's not how insurance supports paying providers. It's just not how it happens. And so it's funny because it's like, what is happening? There's a fear from that provider, obviously, of being questioned or undermined or something.
[53:16]: Because, yeah, I think that provider is very threatened. The credibility is like his or her credibility is very threatened.
[53:27] Sarah: Exactly.
[53:28]: That's what I would get from that. But other people might say, oh, my gosh, there might be, like, a danger in working with these other disciplines. And by putting lay people instead of a doula. It's just very like someone just walked off the street to help you in your labor. They have no training or anything. It's also just interesting, I think, some of the perceived chaos of a physiologic birth, I think, intimidates people to the noises, the sounds and the smells and the lack of control goal, even when people are in control, if that makes sense. When we had our daughter recently, we had her at home, and my older daughter was present, and my mom was there, and my mom had never seen a birth, and obviously my daughter had never seen a birth, and so there was a lot of conversation about noises and sounds and what's okay and what's not okay. And I remember telling my mom, if you peek in and it seems like it's not going okay, quote, unquote, it is. My midwife will come and tell you if something is changing and something is actually wrong, that I may make lots of noises. I may be saying that I don't want to do it anymore. These are all normal things that you might hear because you've never seen it before. And she didn't experience that same type of birth when she had me. It was different for her. And so letting her know those things. And we talked about it after. He was like, yeah, I was trying to sleep, and I couldn't because I kept hearing you. And I could not myself to be a little worried. But you had told me that if I really needed to be worried, someone would tell me. And so I knew that it was okay. And I was like, great. Basic. Exactly. Such a basic that so many people just don't know. Like the couple of births when I worked labor and delivery, where people would come in ready to roll. Right. They're crowning in the elevator, in the wheelchair. It was just pure chaos. And it didn't need to be. All she needed to do was give birth to her baby. And everyone acted like they still needed to do all the things, ask all the questions, start the IV. We can't find the baby's heart rate. Well, yeah, because the baby's plus four. The baby is almost out. In the time that we're stressing this mom out about it, we could be trying to support her in these last few minutes, because this probably wasn't her plan either. Her plan may have been a medicated birth and not this supporting her through that, and then you have all the things in order to do. It's just different.
[56:15]: Michelle: Oh, man. So different. So in your antipartum care of your patients, do you screen for things like childhood sexual abuse and domestic violence?
[56:26] Sarah: I do, yeah. That's actually a standard part of my charting system. I have I have a client portal on my charting system where they go in and they fill out their health and health history and then there's a social history aspect that it has them fill out and there is a spot for both physical or emotional or sexual history with anything. And I think that that's a huge part of not just the birth side of things, but becoming a parent that really has to be addressed and talked about because birth and parenting kind of just cracks you right open even if you want it to happen. And I have seen a couple of people with somehow enough willpower to not crack open like that. But at some point you'll crack. At some point you have to reach that raw part of yourself and talking about it's very important.
[57:23]: Michelle: Yeah. And anyone that has suffered through any of that, it's going to affect their view on birth and the whole process and vulnerability and trust all of those things that you need to have when you are going through the birth process. So I'm glad that you're touching on that. Let's talk for a moment about prenatal breastfeeding education.
[57:59] Sarah: Okay.
[58:03]: Michelle: My listeners know that I'm a certified lactation counselor and I got involved in teaching Best Beginnings way back in 2008. And at that time we were working towards the Healthy People 2010 goals of having initiating breastfeeding rates, exclusive breastfeeding at three months and exclusive breastfeeding at six months. We didn't meet those goals, obviously, and then they went to 2020 goals and we haven't met those goals either. And what I found as a lactation counselor talking to many moms is that very few of them got any kind of prenatal breastfeeding education, which I thought was so sad because they had so many opportunities with their provider every month to talk about that and these conversations weren't being had. And sometimes the very first time we were talking about it was right after they had delivered and we're putting the baby skin to skin and we're asking that age old question, did you want to breastfeed or bottle feed? Which thankfully we got rid of that and they were kind of like, well, I don't know, which is you're too late to the game there, right?
[59:35] Sarah: Automatically.
[59:37]: Michelle: Yeah. So what do you talk about prenatally and then how do you encourage postnatal breastfeeding?
[59:46] Sarah: Yeah, the prenatal breastfeeding education, again, it's kind of like a demographic thing as well. A lot of the families choosing a midwife and choosing to have a home birth kind of already have a goal in mind for breastfeeding, which is kind of interesting that they at least anecdotally appear to be hand in hand. I have come across people who want to plan on bottle feeding or want to plan on supplement feeding, but for the most part everyone kind of their goal is to breastfeed. But in terms of the support and education, I do. Antonatally I actually have an IBCLC come towards the tail end of the pregnancy sometime between 34 to 38 weeks. It kind of depends on when it matches up for both her and the visit schedule for my clients. But she comes and does a whole kind of the whole visit is about breastfeeding education. It's about that first lapse. It's about the first couple of hours, the first day, the first weeks, nipple care and silver rest and hakas and pumping and bottles and we kind of go over all the things and she gives them a handout too. But even before that, I kind of ask again, it's more that third trimester because I think the focus for many people in those first two trimesters is just like, well, the first trimester is just survival. When am I going to feel better? When do I not feel like I could sleep all day long and eat nothing, right? And then that second trimester, you're finally feeling good, you're starting to maybe plan your baby sour you're thinking about the baby things you need. And then the third trimester, I think is kind of when it becomes real for people that they're going to be having a baby. And so in that third trimester, I usually ask my clients, what questions do you have about breastfeeding before we have the IBCLC come and talk to you, what specifics do you already have questions about? And some people it's like everything, I just need to know all the things and then maybe I'll have questions and then other people have specific questions based off of maybe what they've seen a family member or a friend go through, what their mom might have gone through with them. And we kind of have a focused conversation more on that if they have those specific questions. But a big thing for me to let my clients know about is that in the first moment and hours after birth, getting not just baby to breath, but nipple stimulation, in is very important. And so if someone has a birth where there's maybe a little bit of bleeding or maybe baby needs a little bit of help and we kind of have to not go immediately to getting a latch going, like getting some sort of hand stimulation going or something like that. And then talking about how in the first 24 hours, having baby nurse frequently. And that doesn't necessarily mean it's going to be this great, gulpy, beautiful, but getting the nipple stimulation, getting baby on the breast and then we talk a lot about antatal expression of colostrum and the benefits to that. And I think it's like this evolving conversation of what it will all look like that way when we get to it, it's not as glaring because when you're in that immediate postpartum haze of hormones, that's not a good time to be educated on anything, really, because you're in this primal I have my baby. I don't want to hear anything else. You're just in a different stage of brain space. And so I try to touch all those things prenatally so that if we get to a point where we're like, okay, now the latch is a little funky. Now baby does look like they have a tie. Baby had kind of a long pushing stage, and so they may have tension, like, here's recommendations for body work. That way those types of things don't seem as jarring when the time comes.
[01:03:59]:Michelle: Yeah. Wow. Sounds like you have a really comprehensive approach to great approach. Well, Sarah, thank you so much for being my guest today. I have learned so much about what you do as a midwife, and it's a really fascinating profession. I love it. So thank you for coming on and talking all about it.
[01:04:21] Sarah: Of course. Thank you for having me.
[01:04:23] Michelle: For people that have questions, where can they reach you?
[01:04:29] Sarah: I have a website. It's Wildflowerbirthandwellness.com. It's the same handle on Instagram. And then for email, it's wildflowerbirthandwellness@gmail.com.
[01:04:41]: Michelle: Okay, great. All right, well, listeners, if you have any questions for Sarah, please reach out. And, you know, Sarah, at the end, we do the five-minute snippet, so it's just five minutes of fun. Are you ready to play? Yeah, I'm going to start my timer. Let's just go. Would you rather be great at sports or trivia?
[01:05:11] Sarah: Trivia.
[01:05:13]: Michelle: Trivia. Fun. Are there any things that you're superstitious about?
[01:05:19] Sarah: Oh, superstitious. I don't think anymore. I think I used to be superstitious about the kind of average things don't walk under a ladder, don't open umbrellas inside. But I think I've embraced that. Those are probably not superstitious. Maybe they're actually good luck and that's what no one wants us to do.
[01:05:38] Michelle: Them or saying the Q word at work.
[01:05:42] Sarah: Right, right. Yes, exactly.
[01:05:46] Michelle: Would you rather have hair on your back or go completely bald?
[01:05:52] Sarah: Go completely bald.
[01:05:54]:Michelle:  There are wigs.
[01:05:56] Sarah: Right.
[01:05:59] Michelle: What's the most annoying bill you have to pay?
[01:06:05] Sarah: Coming up? It's going to be my student loan. The forgiveness ends next month, so that's the one that's going to be the worst to pay.
[01:06:15] Michelle: Yes, I hear you.
[01:06:17] Sarah: Wow.
[01:06:19]: Michelle: Would you rather go back in time and prevent the Chernobyl disaster or the Holocaust?
[01:06:26] Sarah: Oh, that is an impossible choice to make.
[01:06:31]: Michelle: I know, right?
[01:06:32] Sarah: Yeah.

[01:06:33]:Michelle:  Let's do them both.
[01:06:34] Sarah: Yeah. Both. Yeah. I would not want to pick between either. I'd want to pick both.
[01:06:39] Michelle: If you were in charge of the vending machine in the office, what three items would you have in it?
[01:06:49] Sarah: Topo Chico, the sparkling water. I love it. What else? Probably dark chocolate bars. Yeah, dark chocolate bars and some sort of fresh fruit that would be harder to stock, but some sort of fresh fruit.
[01:07:11] Michelle: I want to work in your office. Would you rather be in a music video with Taylor Swift or Beyonce?
[01:07:20] Sarah: Beyonce.
[01:07:22] Michelle: Oh, I picked you for Taylor Swift. I don't know why. What's on your to-do list that never gets done?
[01:07:31] Sarah: Oh, probably my laundry. It's never done.
[01:07:37]: Michelle: Just an ongoing load, right?
[01:07:39] Sarah: Yeah, never-ending.
[01:07:42] Michelle: Would you rather be a good listener or a good negotiator?
[01:07:48] Sarah: I think a good listener.
[01:07:51] Michelle: I think you are already, being a nurse. Yeah, a nurse and a mom and a  wife and a midwife. It's like you kind of have to be, right?
[01:08:01] Sarah: Yeah.
[01:08:03] Michelle: What famous person, alive or dead, would you want as your personal assistant?
[01:08:11] Sarah: Lin Manuel Miranda.
[01:08:13] Michelle: He's my favorite.
[01:08:15] Michelle: All right, last question. Would you rather charter a single-engine plane or a helicopter?
[01:08:23] Sarah: Oh, a helicopter sounds fun.
[01:08:29] Michelle: Can you get all your kids and your husband in it?
[01:08:31] Sarah: Maybe just me, though. I don't know. My husband's been on a helicopter. He used to work on a helicopter for his firefighting job, so he's already gotten to be on a helicopter many times. So maybe just my older daughter. She would appreciate it.
[01:08:45]Michelle: That's great. Well, thank you for playing, Sarah. It was a lot of fun. Yes, and it's been so fun meeting you and talking with you.
[01:08:55] Michelle: So you have a great rest of your day.
[01:08:58] Sarah: Thanks. You too, Michelle.