Self-Care and Community Care

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There’s a disturbing obsession with “self-care” in the birthworker/full-spectrum/reproductive justice/caring professions community. Almost every conference we attend, magazine we read, public campaign geared towards us is pushing “self-care” as the antidote to increasingly public discussions of burnout and compassion fatigue. As if busy, caring, self-sacrificing people need one more person to worry about and care for: themselves.

I take issue with this for a few reasons:

While there is increasing critical awareness that “self-care” should constitute more than pampering and self indulgence (a box of chocolates and a bubble bath will not solve all your stress problems), many discussions on self-care just sound absurd to those in the caring professions. Adding more tasks to our day and more things to be responsible for and aspire to is just a recipe for feeling inadequate (“I’m not doing enough taking care of people at work, and now I’m also failing at taking care of myself”). Cut that out. When I do (rarely) discuss “self-care” with clients and colleagues I’m all about normalizing the little tasks they are already doing in their life to care for themselves and re-framing them as “self-care”, or if I’m adding a task, I keep it to something that will take less than a minute.

    • Taking your dog on a walk is self-care! Moving your body and being outside! Spending time with another creature!  

    • Texting your friend back after a few days of ignoring text messages is self-care! Connecting with community! Reaching out to reinforce friendships!

    • Staring at Facebook on your phone while sitting on the couch is self-care! It’s nice to disconnect from one world and be in another when you feel overwhelmed!

    • Taking an extra minute in the shower just to lovingly clean your body is self-care!

Yesterday, in therapy, after complaining about how tired and stretched-thin I was, and how this was my first real day off in a long time but I still had a million things to do, she paused and then asked me, “What are you going to sacrifice today, for your own care and happiness?” She explained she would often ask people what they were going to do that day to take care of themselves, but with someone like me, felt the more productive question was what was I not going to do. The best I could come up with was giving up feeling guilty for inevitably not completing my list of things to do that day.

But the biggest issue I take with a push for us all to improve our “self-care” practices, is it lets our friends, family, and community off the hook for thinking about and caring for us. If I’ve spent all day caring for people, when I come home, I just want someone else to take care of me. It is totally appropriate that my husband cooks dinner and packs a lunch for the next day for me. When it was my birthday, a colleague went out and got special cupcakes for me and we all celebrated at practice meeting. When I hosted a pay-what-you-can retreat a few years ago for dear colleagues and friends which resulted in me having to personally cover a lot of costs (because birthworkers are broke! pay your support people!), one participant took some extra nannying shifts and took me out to dinner the next month, paid for dinner, and handed me $300. She just couldn’t live with the community not supporting me after all the work I’d put in.

These kinds of gestures typically make me uncomfortable. I try to deflect them, tell myself I don’t need them, or deserve them, or other folks are stretched thin too so I can’t accept… but instead, lately I’ve been thinking a lot about the responsibility we have, in community with people in the caring professions, to think about them and take care of them. They deserve it. It is absurd to ask burnt-out folks to also be responsible for healing themselves. Maybe when they’re less frazzled they can take loving steps toward their own healing, but if you’re observing your loved one/community member tired from caring for others all day, and your advice is “take better care of yourself” : you’re doing it wrong. Take care of them yourself. Give them back an ounce of what they exude to others all day. Help them feel loved and cared for and held by community.


What to Expect During and After a Miscarriage / Abortion

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Miscarriages and Abortions are extremely common reproductive experiences. About 1 in 4 pregnancies ends in miscarriage, and about 1 in 3 people will have an abortion at some point in their reproductive lifetime. While these experiences may have very different social and emotional contexts, physiologically, the body experiences them similarly.


Lots of people approach me during and after an abortion or a miscarriage describing very normal, expected symptoms and worrying that something is wrong with them. They often feel inadequately prepared by their healthcare providers, or have been helping themselves at home without outside guidance, and are now concerned about their well-being and their bodies. So, here’s what to expect during and after a miscarriage / abortion, what’s normal, what’s not normal, and when to seek more help...


Bleeding / Discharge


Everyone experiencing a miscarriage or an abortion will experience some extent of bleeding. The volume of bleeding will depend on how far along the pregnancy was, what management methods, if any, were used for the miscarriage / abortion, the individual tendency toward uterine bleeding, and many other factors.


Typically if the miscarriage / abortion was spontaneous, or managed by herbs or medications, the bleeding throughout is likely to be heavy. At the onset of the miscarriage / abortion the bleeding is likely to be slow and steady, pick up quickly / heavily, reach a peak at expulsion of the embryo / fetus / large blood clot, and slowly diminish. After the peak experience, the bleeding will taper off to about a medium-to-light menstruation that is normal for the person experiencing the miscarriage / abortion. This bleeding is likely to persist, and eventually taper off entirely for 2-6 weeks. This is an average experience, but there are significant individual variations. Some people bleed a lot less overall, or a lot more overall, and still are within normal limits. As a general measurement, people tend to follow their normal pattern of uterine bleeding (heavy menstrual bleeders tend to bleed heavier during abortions / miscarriages, and lighter menstrual bleeders tend to be lighter bleeders during abortions / miscarriages), though I have seen exceptions to this. Bleeding and pain (see below) are often correlated, as well (more pain = more bleeding as the uterine contractions try hard to expel the contents of the uterus).


Bleeding should not be soaking a maxi pad in 30 min or less, and blood clots expelled should generally be less than the size of the palm of your hand. Heavier bleeding and bigger blood clots may be normal at the very peak of expulsion during the miscarriage / abortion, but should not persist after expulsion.



If an abortion / miscarriage was managed by a D&C, vacuum aspiration, or other instrumental option, there is likely to be much less immediate bleeding following the experience, rather skipping ahead to the spotting / discharge phase.


As bleeding tapers off, spotting may persist for a few days to a few weeks. This spotting is usually pinkish or brownish, as the uterus expels all the last bits of tissue and lining and hormones re-regulate in the body. There is sometimes milky, sticky, slippery, or slightly bloody discharge associated with this phase as well. This discharge should smell like blood, or like your bodily fluids normally do. It should not be rank or foul smelling, and should not be overwhelmingly itchy or irritated.  


If bleeding, spotting, or discharge different from your pre-pregnancy discharge persists for 6+ weeks, there may be small bits of retained tissue left behind in the body. Your body may or may not be able to menstruate while trying to work this out. You may be able to encourage these last bit of tissue to leave at home, at home with help, or in a doctor’s office, with all the same options available to you for instigating the abortion / miscarriage. If your menstruation is able to return, these remnants may expel with the next menstruation.


Next Menstruation


The next menstruation following a miscarriage / abortion is often heavier than pre-pregnancy menstruations. I generally think the next menstruation is a full flush of uterine contents, including any straggling bits left behind after the miscarriage / abortion. The menses is often more painful than expected, with stronger-than-usual contractions and associated heavier bleeding. This can be very normal, within reason. The same precautions around bleeding apply at the next menstruation as did during the miscarriage / abortion and immediate recovery.


This experience (heavier bleeding, more pain) can be emotionally triggering, bringing the person back into the headspace of the miscarriage / abortion that happened weeks or months ago. Be gentle, emotionally, during this time as it passes. This experience (heavier bleeding, more pain) does not usually repeat at future menstruations beyond the one that first follows an abortion / miscarriage.


Pain


As the uterus contracts to expel the contents of the uterus and promote bleeding, and as the cervix dilates to allow passage from within the uterus, people often experience varying levels of pain. I’ve seen pain on a spectrum of slight discomfort to excruciating pain landing someone in the ER. Mirroring typical bleeding patterns with spontaneous, medication, or herbally induced miscarriages / abortion, pain often starts low and slow at the onset of the the miscarriage / abortion and builds to a peak at expulsion of the embryo / fetus / uterine contents, which will taper off and come and go with greater ease over the coming weeks until bleeding stops altogether.

Sometimes, excessive pain comes from the body attempting to expel the embryo/ fetus / tissue, which is stuck behind the cervix and cannot make its way out. The body increases contraction strength to try to manage expulsion, but is unable to. Typically staying active, squatting, trying different positions and hip movements, may help dislodge and expel. In some circumstances, you may need help to expel the tissue.


Again, as a general rule, I find the pain experienced typically mimics typical experiences of uterine pain in that individual person (people with exceptionally painful periods and painful labours/births are likely to have very painful miscarriages / abortions, and people who have more ease around menstruations and other uterine experiences are likely to have less painful abortions / miscarriages), though I have seen exceptions to this.


If an abortion / miscarriage was managed by a D&C, vacuum aspiration, or other instrumental option, sedation or some sort of pain management was likely offered during the procedure. Painful cramps will likely persists for days or weeks following the procedure until bleeding stops altogether.


Fever


If the drug misoprostol (“Cytotec” in North America, may have other trade names in other countries) was used to manage the miscarriage / abortion a temporary, immediate spike in temperature is common, and an expected side effect. This temporary temperature spike is often accompanied by shaking and chills. If this temperature spike persists beyond 24 hours and/or beyond the expulsion of uterine contents, it is now a fever, and may need medical attention (see below). Taking antipyretic medications (Tylenol, etc.) will mask the fever, but not treat the underlying reason for it.


Tenderness


Uterine tenderness is common and expected following an abortion / miscarriage. Many people describe that they can “feel” the organ in their body in a way they normally can’t, like a bruise, a dull ache, or like being punched in the gut. This dull ache, and general tenderness may persist for a few weeks, accompanied by occasional pain / contractions. Sharp, shooting pains, especially when touching the uterus (just over / behind the pubic bone), especially if accompanied by a fever or foul smelling discharge, are not normal.


Emotional Distress


Beyond feeling tender physically, people often feel tender emotionally. Even when the abortion / miscarriage was wanted, necessary, and/or a relief, and especially when it wasn’t, there is an unavoidable major shift in hormonal makeup in the body following the end of a pregnancy. Feeling especially tender or distressed emotionally is common and normal. Feeling relieved and happy is also common and normal. Taking extra care and gentleness during this time is important.


Perinatal mood disorders (postpartum depression, anxiety, OCD, rage, etc.) are not at all common following an abortion / miscarriage, but are within the realm of possibility. If dark thoughts plague the mind, and sadness is the overwhelming feeling for 2+ weeks, seek professional help for caring for the mind and heart.


Future Fertility


Fertility returns at different rates in individual bodies following an abortion / miscarriage. Ovulation may occur irregularly, including earlier or later than expected, and with or without the typical other fertility symptoms in the body (cervical fluid, temperature increase, cervical position, etc.) If a person was previously relying on a method of birth control, and they do not wish to conceive again right away, they might consider resuming their previous, or starting a new form of birth control. If a person was previously relying on fertility awareness based methods of fertility management, I recommend back-up methods of birth control for any potentially fertilizing sex for 2-3 months or until the body is cycling normally again.


Good evidence over the years has shown abortions, even multiple abortions do not / should not affect future fertility. People who have had abortions should be able to conceive spontaneously in the future without increased difficulty.


After a person experiences one miscarriage, their chance of experiencing another remains the same in future pregnancies (about 20-25%). After two miscarriages, their chance of miscarrying in future pregnancies increases by about 5% (to 25-30%). After three+ miscarriages, their chance of miscarrying in future pregnancies increases by about 10% (to 30-40%).



Common Precautions to Prevent Complications


In order to support the body during and after abortion / miscarriage, there are a few general principles in caring for the body, as well as specific pieces of advice, to promote health and well-being and prevent complications:

  • Try to keep things out of the vagina in order to prevent infection for about two weeks or until bleeding has stopped. This includes any sexual acts that involve penetration, tampons, menstrual cups, and fingers. If you cannot or will not follow this advice, consider extra immune system support and be vigilant for signs of infection in the body. Read more here about my experience with sex after my second miscarriage, and why I’m glad I didn’t wait the two weeks!

  • Monitor the body for symptoms of infection (see below) by observing discharge from the vagina as well as taking your temperature daily until bleeding has stopped.

  • Monitor your bleeding. Keep an eye out to make sure you’re not experiencing excessive blood loss (see below).

  • Keep an eye on your pain control. If you are suffering, consider taking extra-strength ibuprofen (trade name Advil in North America)

  • Surround yourself with loving support that tends to your heart and soul. If you are unable to get compassionate care from those that surround you, consider reaching out to your local full spectrum doulas, or seek full spectrum doula care long-distance.



What’s NOT Normal (and when to seek help)

  • A uterine infection is no joke. Apart from being extremely painful, unchecked it could lead to lasting complications in the uterus, including the need for more instrumentation, antibiotics, and a potential impact on future fertility. Symptoms of uterine infection include: sharp, shooting pains in the uterus, especially on touch, foul or rank smelling discharge or blood, fever over 101 degrees F or 38.5 degrees C lasting more than 24 hours, and generally feeling as if you have the flu. Seek medical attention.

  • While individual bodies can tolerate different amounts of blood loss, excessive bleeding in general, otherwise known as hemorrhage, can be life-threatening. Soaking a maxi pad front-to-back, side-to-side so there’s no white spots left on it in 30 min or less is too much bleeding. If this happens for one or two 30 min spans at the peak of expulsion during the miscarriage / abortion, and you feel physically okay, this may be acceptable, but over an hour of this pattern and you should seek medical attention. At any point if bleeding is present and you feel like fainting, or like skin is cold, clammy, and/or pale, your body is not coping well with your blood loss (no matter how big/small it seems), and you should seek medical attention.

  • If the pain is excruciating and unbearable even after Ibuprofen, increasing activity and changing positions, and having loving support present with you, seek medical attention.

  • If you are experiencing unmanageable depression, anxiety, OCD, rage, or other perinatal mood disorders, seek the help of a skills mental health professional or clinic, especially that have specific experience with perinatal mood disorders.

Natural Cervical Softeners

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Cervixes are dynamic, incredible organs that can change shape, consistency, feel, and even almost disappear entirely at different points of menstruation, ovulation, pregnancy loss, and birthing.

Most of the time, when we’re not menstruating, and not ovulating, our cervix is relatively hard and closed tight. This is an evolutionary mechanism that keeps our cervix from just hanging out open and potentially being a pathway of vulnerability into the body. By contrast, the cervix must be open at least a small amount during menstruation and ovulation, and the regular discharge during these times still acts as protection despite our open cervixes.

But there are times, when our cervixes are tightly closed, when we’d like to encourage them to soften. These might include:

  • You’re waiting on your period to come and want to encourage it to come faster

  • You’re preparing for an IUD insertion

  • You’re preparing for a menstrual extraction

  • You’re preparing for an abortion

  • You’re experiencing a missed miscarriage and want to encourage the body to release

  • You’re pregnant, full term, and ready to encourage the body to go into labour (or you need to go into labour now, for some particular reason)

Essentially, a time when you know something is going to go into or come out of your cervix and you want to make that easier and less painful.

When softening and opening a cervix, one can either rely on natural methods (herbs, oils, etc.), or on pharmaceutical and mechanical methods.

Over years of practice and soliciting advice from other skilled practitioners, these are the suggestions I typically extend to people trying to soften their cervixes without pharmaceuticals or mechanical dilation. I usually caution it can take a few days to work (in the case of someone not pregnant or in early pregnancy), or weeks to work (in the case of advanced pregnancy), and as everyone’s body reacts differently to different methods, we can’t guarantee efficacy with any one suggestion.

In addition, it would be important for the person looking at softening their cervix to consider any other vitamins, herbs, supplements, or medications they are on, and consider if there may be any interactions with their chosen cervical-softening-ally.

Parsley

Fresh parsley leaves inserted vaginally can work wonders at softening a cervix! Flat leaf or curly leaf parsley are both fine, though I prefer the flat leaf. I always select organic parsley since it’s going inside by vagina. I take a small bundle of sprigs, held between my fingers, stems trimmed to just be about 2 inches long (or to your preference), and insert it vaginally so the leaves are resting up against the cervix. It’s a little uncomfortable at first, but the heat and moisture of the body softens everything quickly and you don’t really feel it. Change this bundle every 8-12 hours. I usually advise this for about three days in advance of needing the cervix well softened. Pro-tip: because our mucous membranes are connected in the body, you’re likely to taste parsley in your mouth, while it is held in your vagina. Wild!

Evening Primrose Oil or Borage Oil

The gamma linolenic acid (GLA) in evening primrose and borage oils have well-known cervical softening properties and have been used my midwives, physicians, and all kinds of healthcare providers and supporters and a gentle way to help cervixes soften and open in a variety of contexts. Very little research has proven benefits, but experience shows efficacy.

The GLA content of borage oil is higher than that of evening primrose oil, and borage oil is often considerably cheaper. However, you’ll want to source the highest quality you can afford, and there’s often more a variety of quality, including high quality, evening primrose oil available.  

Whichever you take, you can choose to take it orally or vaginally. I see slightly faster/better results with vaginal administration, but it’s up to you!

  • Oral: take two capsules twice daily

  • Vaginal: insert two capsules vaginally as high up as they can go before you lie down to sleep. Consider sleeping on a towel or with a pantiliner as it might leak.

You can also get oil that is not contained in capsules, or open the capsules to get the oil, and put it on your finger and apply it directly to your cervix if you feel comfortable with that.

Again, you’ll have to do this for a few days (in the case of someone not pregnant or in early pregnancy), or a few weeks (in the case of advanced pregnancy) to see results

Lobelia Tincture

I don’t have personal experience with lobelia tincture but have had enough trusted friends and colleagues recommend it that it bears mentioning here. More than once I’ve heard of friends attempting menstrual extraction, with a speculum in place visualizing the cervix, have the person take drops of lobelia tincture on their tongue and visually see the cervix soften before their eyes. Lobelia is also commonly included in traditional labour-prep tinctures as an element to encourage labour in a term pregnancy.

Typically, I hear a range of recommended doses from 1-6 drops (not pregnant, early pregnancy) to 60-120 drops (full term pregnant), often just once. Individual bodies may tolerate more or less. Too much lobelia often causes vomiting.

Cervixes are dynamic, incredible organs that shift between hard and soft on their own given a variety of factors, and typically in response to hormonal changes and events (menstruation, ovulation, pregnancy, birth, etc.). AND we encourage our cervixes to soften up even when they’re in a rigid phase if we need to, using plants and oils.


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What is "Full Spectrum" Care?

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When I talk about being a midwife and providing care to community, I refer to my care as “full spectrum”. This means I take care of a broad spectrum of people through a broad spectrum of experiences and outcomes, related to reproductive health. It means I go beyond taking care of families and individuals through pregnancy, birth, and postpartum, and also include midwifery support for abortion, adoption, pregnancy loss, fertility, birth control, pap smear, IUDs, and more. This broad spectrum of care is within a traditional midwifery scope of practice: which included community care for life passages including puberty, pregnancy, menopause, death, basic pediatrics and adult healthcare, and deep knowledge of reproductive health and needs. This care in community is essential and important, and the knowledge in one person to take care of it all is very meaningful in community for building trusting relationships with those supporting your health.

The division and breakdown of reproductive health services into specialties is a new development in medicine, and one which I would argue is not going very well. Clients often speak to me about how strange it is they could see a midwife for this pregnancy and birth, but if they wanted an abortion in the future they often would go to a clinic and see a doctor who’s a total stranger to them who they may never see again. And then their family doctor will do a pap smear, but they’ll go to the sexual health clinic for their IUD, and a pediatric clinic for their 6-month old’s cough, and a specialized clinic if their sister wants advanced fertility testing. Now of course, part of this is specialization, and when health care workers can focus on one aspect of care they can learn it really well and offer deeper insights, but when you see too many specialists in pursuit of your own healthcare the bigger picture of who you are is often lost and the care just boils down to a service provided that day only. Taking care of a full spectrum for our clients can help them get care in fewer, trusted places who know the whole of them and their history more carefully.

I was first introduced to this terminology through the “full spectrum doula” movement as an explanation and naming of the care doulas, midwives, and other care workers in community have always done: provide for all kinds of people through all kinds of experiences. “Full spectrum” doulas provide doula care for birth and postpartum, as well as for abortions, adoption, pregnancy losses, gynecological appointments, surrogacy, fertility, etc. They provide informational, practical, and sometimes spiritual support for people through all sorts of reproductive experiences.

While the care full spectrum doulas provide is nothing new, describing the care specifically as “full spectrum doula” work is a relatively recent development most likely traced to The Doula Project and the hard work of Miriam Zoila Perez in New York City in the mid 2000’s. Other full spectrum doula collectives cropped up throughout the United States to serve their communities (you can see a map of most full spectrum doula collectives in North America here).

I was introduced to the concept through Full Spectrum Doulas in Seattle. I had signed up for a swanky 4-day DONA doula training at a local University, and on the last day when they discussed community resources, they mentioned Full Spectrum Doulas. While much of the week had felt like going over common-sense support strategies and learning about our local hospitals (helpful, but not exactly what I’d hoped for), I felt like it had all been worth it to learn about this organization in our city doing the work I really wanted to do. I met up for coffee with their Core Organizers to hear more about what they were about and how I could get involved. They were doing excellent work on the ground and I ended up training with them to be an abortion doula, becoming a Core Organizer, and conducting abortion doula trainings over a few years while I lived in Seattle finishing my BA.

The full spectrum doula movement in the US has done great work at bringing attention to doula communities that outcomes besides healthy, happy births, deserve doula support. They’ve also helped other communities (abortion communities, adoption communities, etc.) see that doula-style care can and should be an integral part of these reproductive experiences. My greatest happiness in watching and participating in the evolution of the full spectrum doula movement is the current pushing to embrace a truly full spectrum. While most full spectrum doula projects originally focused almost exclusively on abortion doula work (critical, necessary work), most are now pushing their own boundaries to expand and include the full spectrum they long boasted about.

I’d like to see this same evolution with midwifery care, particularly out-of-hospital midwifery care, in the US and around the world. While a portion of midwives are, and always have tended to a full spectrum of experiences, the majority of midwives are predominantly caring for people during pregnancy, labour, birth, and early postpartum. I’d like to see us reclaim a more traditional scope of practice, including a broader, more full spectrum approach to care for our communities.