Obstetras

Hospital Nuevo Amanecer en Vivo

A couple of low quality cell phone videos of Hospital Nuevo Amenecer to fill in the imagination!

600-715pm

The lights flickered and dimmed. The dark of dusk fell over the barrio as the lights went out in the Cocal. They say that in December the lights fail more often than not. Everyday for the past week the lights have gone out at least one time. I found myself lighting the way with my cell phone, its small square of yellow guiding me through my dark home. I searched for my teal green scrubs and pulled them on, feeling my way for the drawstring that distinguishes the front from the back of the shapeless pants. I locked up the top of my home and walked down the stairs to the kitchen to throw together a simple dinner to bring to the hospital. There had been avocados in the market earlier that morning, so I threw one in my bag with a package of mini toasts. Outside the lingering light from sunset carved out silhouettes of trees, buildings, and neighbours walking to their homes. Armed with my cell phone I passed through the metal gate and dared to trudge through the thick clay colored mud that currently lines the alley from my house to the street. At the mouth of the river that is my alley I awaited a taxi to whisk me though the pitch black for a night shift at Hospital Nuevo Amanecer.

As we sped down the gravel road there was a stillness that I could detect in the air. When the lights go out the chugging generator of the city quiets itself, and the black night draws people into their homes, away from the possible dangers lurking in the shadows. Quite nights like these make for lovely births.

I entered the hospital and walked back to Labor and delivery at 600pm. The delicate hum of the air conditioner whispered in the background mingling with the heavy breathing of two women in labor. One, the 43 year old matron, preparing to have her ninth baby stood in the corner providing guidance to the other, 20 year old first time mom. It was a crap shoot who would deliver first, but I placed my bets on the experienced matron. I led her to the delivery table, carting the small plastic bag of blood that was transfusing into her vein. An older woman, with anemia, and a history of many deliveries is at high risk for a hemorrhage after birth. I mentally prepared myself for the worst, running through my steps for managing a postpartum hemorrhage. The matron climbed onto the table, telling me that this was her fifth delivery in the hospital. She grinned, revealing a smile only half full with teeth. She was complete and began bearing down like a professional. I was the only midwife available to attend the delivery as the other one had stepped out. Gradually her baby´s head made its journey from inside to outside. Her neck was rounded by a tight loop of cord too tight to slip over her head. A quick somersault and the baby´s body was delivered and the cord then removed. No hemorrhage. That was at 700 pm. As I am waiting, and waiting for the placenta to deliver I´m starting to become concerned that she might have a retained placenta as I hear the deep guttural groans of a pregnant woman who is ready to bring her child to light. Finally the placenta slips out and I pass the multiparous patient off to the young physician for her to inspect.

I slip my head into the labor room and see the first time mom eyes wide with surprise staring up at me. I whisper to her, “its time” and help her to her feet. We move to the delivery table and she clambers her way up onto the blue vinyl cushion. The black curls on her baby´s head are just barely visible as she begins to bear down with all her strength. The midwife comes up to me and asks me if I’m going to cut. I shake my head no. “I think she´ll stretch”. “Don’t do it then” she says. I sense the still black night outside, hear the buzz of the air conditioner, and feel honoured to be sealed up in this labor and delivery suite at the end of the earth. The first time mom pushes with control to deliver her baby boy, tight nuchal cord, with one hand reaching up and out into the world. She delivered beautifully and empowered. Of course there was a little tear, but nothing a little suturing couldn´t fix. That was at 715 pm.

Sexy Underpants

A night at the hospital is always full of surprises. You never know what it will hold. Some nights nothing happens and I will pass the hours trying to sleep on a mattress that we open up on the floor, lying next to another nurse clad in white from head-to-toe while people come and go, knocking on the door, eating fried plantains, and searching for nursing students.

Last night began slowly. An empty labor and delivery room is nothing new to me. I often start my shifts either day or night chatting with the nursing students and midwives. When it is a night shift I often hope for one of two things: that the night will be slow and we will sleep, or that it will be so busy that the 13 hours will fly by.

At 830 still no patients. I spent an hour talking to one of the physicians, and then a friend came by for a visit. I sat outside in the thick night air, watching the moisture create halos around the street lights. We talked and watched pregnant women holding large bellies stream by, but not one of them in labor. Suddenly I heard the electronic samba of my phone ringing. It was the doctor. He needed me to come back and attend a birth. Some how a pregnant mother, cervix completely dilated slipped past me into the labor and delivery suite. I hurried back my clogs clacking against the smooth concrete floor, opened the door to Labor y parto, and approached the labouring mom. One look at her told me this baby was definitely on its way. The other midwife had stepped out, so it was just me, the nursing student, and the physician who was busy scribbling a note, back turned to the patient. I suited up into my surgical green cloth gown and donned a set of gloves significantly too large for me, tugging at the floppy latex thumbs to keep them from falling off. The mother began to push and a bulging bag of waters was instantly visible, black curled hairs from the babies head swaying beneath the membranes. Now, in the majority of deliveries the baby follows a certain dance that I have referred to before as the cardinal movements. The baby descends into the birth canal, flexes his head downward with his eyes pointed towards the mother’s back. When the baby begins to crown the head extends up and out of the birth canal, turning slightly to one side. Following this the shoulders take a turn so that they are parallel to the birth canal and with this a fold at the hip and the baby’s body slips into the world. That is, that most babies are born this way. As this mom began to push I applied my fingers to the baby’s head, creating pressure so that his head would not fly out and tear the mother. To my surprise this little one popped out, sunny side up, eyes to the ceiling, gazing directly into my own. He quickly slide into my hands and up onto his mothers belly. This technically is called a direct occiput posterior delivery, but there was nothing technical about this delivery, it was simply one human being being born staring into the eyes of another supporting his head.

Later that night we had another delivery. A very sweet woman delivering her second baby. She progressed rapidly to complete and we brought her to the delivery table. She was scared, but with gentle support she was able to find her inner strength and bring her child to light.

There are certain things in life that make someone feel like a midwife. One is empowering a woman to birth her baby with the power that she innately has. Another is teaching another woman how to attend a delivery. Last night was when I transcended from student to midwife to teacher. As I prepared myself to attend this delivery the nursing student whispered in my ear, ¨will you let me try this delivery¨. She put her gloves on and laid her hands on the woman’s perineum. She was brave and I noted that her hands were steady and her eyes clear. I felt the fear or apprehension that any teacher must have when the give over the reins to their student as I laid my hands over hers, applying pressure against the mother’s perineum trying to prevent any tearing. It’s very difficult to let go as a practitioner. I wanted the best for this patient, but also wanted to give this student an opportunity to learn the art of midwifery. Together ours hands pressed, flexed, and welcomed this babe. As the head slid forward we both checked for a cord. We both grasped our hands alongside the babies head to ease the shoulders up and out of the birth canal. The student was exhilarated as she placed the newborn up on her mother’s abdomen. I was proud to have had the opportunity to share my skills, although new skills, with this student. We delivered the placenta together, me whispering instruction into her ear. We inspected her perineum and discovered a mild tear that would require suturing. And there I was, a new practitioner instructing a nursing student in how to ease the silver half-moon needle into the red tissue, rounding it up and out. It was an amazing lesson in midwifery to support the growth of another student, and quite a personal lesson in letting go.

One of the most midwifery related actions that we do at Hospital Nuevo Amanecer is dress our patients after the delivery. We carefully bath them with wiry gauze that has been hand folded when there is nothing else to do in the labor and delivery suite. We remove the dried blood and streaks of amniotic fluid. We then help the mother to cross her legs together and slip on her undergarments in which we have placed several absorbent kotex pads. Our patient had been sobbing through the delivery and was still weeping as we cleaned and prepared her. As we pulled the underpants out of a green plastic bag that her husband had brought for her she began laughing hysterically. We all broke down, laughing like crazy as she said ¨of all the underpants, this is what he brings me? I have a mountain of underwear and he sends me back these? These sexy underwear?¨ And we all laughed until it hurt as we helped her slip on the chocolate brown, satin panties with a large cut out key hole and silk bow in front.

Birth and Death

The saddest moment of a pregnancy must certainly be when a woman hears that her baby has died. All of the hopes and dreams that she had for this unborn and unknown being lost like grains of sand slipping through ones fingers. Part of the psychological transition into motherhood comes when the woman feels the first flutters and twirls of the growing fetus within her womb. She identifies at once that this creature is of her, but is its own unique life coming to being. With this acknowledgment she begins to wonder, will she have my curly hair, will he bear the family nose, will she be kind, will he be funny...and just like that, before the child is even born the parents have cultivated a garden of hopes for their little one.

I can't begin to understand the sadness that my patient felt when she went to the clinic, concerned that her baby hadn't been kicking within her for the past two days and discovered that her baby had died. Surely the nurse or doctor applied cold gel to the plastic tip of the hand held doppler and searched in vain for the quick click-click-click of the baby's heartbeat. They probably told her that they were sorry, that it was too late, that her baby hadn't made it. After this heartbreaking news they must have informed her that she would need to go to the hospital to have her labor induced.

When I met her she was 5 centimetres dilated in labor with her first baby who had died. She was exhausted, her golden skin looked sallow, her eyes sunken with a far away look. Sweat beaded on her forehead and upper lip. She grasped her IV pole from which a bag dripped oxytocin into her veins. A cruel twist of fate this labor. Normally a labor of love and pain, women know that on the other side they will greet their long awaited baby. In a developed county this woman would be offered pain medication or an epidural to ease her through the difficult labor. Here it is not an option. With each contraction she reeled in pain. She moved from sitting to standing, to lying, lacking the strength or will to move gracefully between positions. She could not find comfort and cried out to God to see her through as each contraction surged through her. I sat with her and tried to calm her, knowing that her suffering was deep.

When her cervix was completely dilated we brought her to the delivery suite. She lay on the table, forlorn. She pushed bravely. I guided her, my hands fearful, never having delivered a baby that would not be alive. The delivery was difficult. Normally a baby rotates into the mother’s pelvis in a dance called the cardinal movements. The head flexes, then extends as it’s born, followed by a 45 degree turn at which time the shoulders align vertically before the rest of the body is expelled. But a baby that has died does not know the movements. The head does not gently extend, the shoulders do not rotate. The baby's body would not deliver. I found myself stepping aside as one of the doctors with more strength moved in to extract the baby. I had wanted so badly for the delivery to be gentle, to offer this woman just that small kindness after so much suffering, but it was not meant to be. I stood at her side as the baby was lifted to her abdomen. I wrapped her in the sterile green surgical drapes and carried her to the neonatal warmer, gently placing her onto the bed. It was overwhelming that she did not breath. Her right arm curled up towards her tiny mouth, left arm over her belly. Her small legs were pulled upwards in a tuck. She looked ready to take her first breath, ready to startle and fan her arms up and out into the world. She was perfect.

I moistened some gauze and began to wipe her face, eyes, hair, trying to make her as clean as possible given the conditions and lack of running water. She had been expecting a little girl. Her family passed back a rose pink princess dress with puffed sleeves and layers of sparkly tulle. After measuring and weighing her I fitted her white cloth diaper on. I smoothed the pink princess dress down over her little body, placed the pink hat over her moist black hair. I pressed her left foot onto an inkpad and placed a foot print on a piece of paper for the family to take home, then slipped on her pink socks. She looked like a newborn Cinderella.

One of the nurses brought her daughter over to her mother, whose eyes welled with tears. The baby was brought out to family waiting in the hall.

I wanted this blog to be a tribute to this brave woman. A remembrance for her daughter.

The Birthday Gift

The Saturday after my birthday I went in to Labor and Delivery. Julia, one of the Midwives from my radio show group was working. When I came in she generously supported me in attending our patients and births that day.

When the shift began there was a 17 year old first time mom. Her labor had been moving slowly throughout the night and she struggled to keep her eyes open between contractions. On exam she measured 5cms, the same as the night before when she was sent over to labor y parto. As I've mentioned in earlier posts there is currently an initiative to include traditional practices in facility-based birth in an effort to respect and humanize birth in the RAAN. The young woman's mother passed a Styrofoam cup half full with brownish liquid, green particulate flowing throughout. The girl took it down in one drink. One hour later another batch of the brew was passed back to Labor y Parto where one of the maternity nurses bathed the girl’s abdomen and sacrum in sweeping circles with the tea blend. The tea herb, Escoba Lisa, is also referred to as Oxy-casera, a powerful labor inducer. It is rumored that the women who come into labor and delivery with powerful contractions and booming labors have been drinking these traditional remedies to hurry the labor process. Our patient moved slowly but surely though her labor to arrive at 8cms by the afternoon. An IV was started and oxytocin flowed at 8 drops per minute into her vein. The girl’s mother came back and held her hand as she cried out 'mamiki, uba latwan, mamiki, uba latwan' over and over during contractions; her own mother´s tears slipped down her cheek watching her daughter's pain. Another woman was called back to assist in the traditional healing of this young woman. She was a large (hermosa) woman with milk-chocolate skin and peroxide orange hair. She held a bundle of green plants waded into the palm of her hand. She crushed the plant she told me was named Africa, then rubbed it over the laboring woman's abdomen repetitively making the sign of the cross, then moving to her sacrum. The plants were squeezed and squeezed until a thick green juice was extract and dripped on the girl’s forehead. This was followed by fanning the patient and tucking the bundle of herbs between the woman's breasts.

As we awaited the birth of this woman's babe another adolescent patient was brought into the labor and delivery suite. She was 15 years old, measuring under 5 feet tall, and thick. Her black eyes stared out of her round face with fear, but she also had a look of control about her. She was a patient with preeclampsia, a disorder of high blood pressure that only affects pregnant women and puts both mother and baby at risk for complications and death. In the United States a high-risk patient like this would be receiving medications to prevent seizures, as well as strict vigilance of vital signs…but things are different here. She had an oxytocin drip going to induce her labor...the only cure for preeclampsia is delivery. I took her blood pressure which measured in at 140/100, high, but not so high that we were giving her the PRN blood pressure reducing medication that she was prescribed. The baby's heart rate was very reassuring. Soon after her arrival our traditional medicine patient was complete and ready push. The 15 year old was temporarily abandoned [or allowed to labor without intervention] as we attended to the birth of the other patient's little girl, petite at just 6 lbs and covered in creamy-white vernix, a protective coating that develops in the womb. After finishing up the suturing and writing a note about the birth I turned my attention back to the wide-eyed fifteen year old. I sat at her side and traced small circles on her lower back during her contractions. She would tell me that they hurt very bad when they were over, but she appeared to be coping very well. I checked her and she was 7 cms. About 30 minutes later her bag of water broke on its own revealing clear fluid. Most women's water is artificially broken here when they reach 7-8 cms. It was nice for me to witness her body taking on the process of birth without too much intervention. Shortly after the other midwife checked her and said that she was complete but that the head was still high, that it would be best for her to labor and let the head reach the perineum before getting her on the birthing table. This is also not commonly done as most practitioners are ready to get a woman pushing as soon as she is complete. I checked the baby's heart rate again and it continued to be reassuring. She lay onto the bed and I witnessed her begin to push. I guided her to push when she felt the need, that it was okay. After a couple of pushes she looked at me with her large eyes, grabbing her perineum saying 'its coming out'. I peeked down between her legs and knew she was feeling the pressure of the baby, but was still distant from delivery. No bulging, no crowning. I went into the delivery suite and grabbed a pair of gloves...just in case! As I walked in I started telling one of the doctors who was relaxing along the wall that I was actually more accustomed to attending deliveries in a bed rather than on the birthing table with women in the 'obstetric position'. He was surprised by this as well as the fact that more physicians attend births in the US than midwives, both cases being opposite her in Nicaragua. I went back and sat with the patient again, fanning her with the package of gloves. After about 15 minutes I went to check on my postpartum patient: firm fundus, normal blood pressure, nursing her baby. Her sister was back with her and asked me how much longer the laboring young woman had. I told her that she was close, but not yet. As I turned to walk out of the room the drawstring on my scrub pants got caught on something, coming undone, threatening to reveal my bottom to everyone present. I grabbed the strings at the exact same time that I looked up at my 15 year old patient bearing down with a two inch slit of her baby's hair peaking out. I dove into the room and struggled to get the gloves on that I had left there...I don´t know why that latex gets so sticky and uncooperative when you really need to get them on. I squatted next to the bed trying to keep my pants up as I flexed the baby's head and helped him arrive for his birthday. Julia arrived with a tray of instruments and graciously tied my pants back on for me. The young mother looked so proud and strong bringing this life into the world. The only things I know about her are that she is an adolescent, she doesn't know how to read or write, signing her chart with a thumb print, that she had preeclampsia, and that she was totally in love with her baby at first sight. Her big eyes filled with a pride and joy I haven´t seen in months as she reached out to touch her son laying across her abdomen. Her birth was simply beautiful. It was the most that I have felt like a midwife since I arrived...it was my best birthday gift.

Preparacion de Parto

The Casa Materna is a home for pregnant women within the city of Puerto Cabezas. It is part of a strategy used in developing nations to reduce maternal mortality. Women, who often come from far away communities in order to have their birth at a facility attended by skilled birth attendants, stay at this home to await the swells and surges of labor. The Casa Materna provides medical attention 24hours a day and is a safe space for mothers to be home-away-from-home. The Casa Materna for me is a bit of a home-base where I can check in with nurses that I know, and also is the site of my weekly meetings with obstetric and maternal-infant health nurses to create the radio program Mairin Karnakira-Mujer Poderosa. On a recent visit to the Casa Materna I spoke with two pregnant women who had made the journey from their communities to have their births at Hospital Nuevo Amanecer. Both of them had delivered babies before in their homes. I asked them what made them decide to come here to Puerto Cabezas. One woman answered that previously she lived in Las Minas. There was a health clinic in the town and an obstetric nurse present. She felt safe in her community that if something went awry that she had medical attention quickly available. She explained that since then she had moved to a new community distant from any health center. It took her 3 hours walking to reach the road, and then an additional 8 hours in vehicle to get to the city. She came to the Casa Materna so that she would have medical care at her fingertips. The other woman said that she had been told that it was 'better' to have her baby in the hospital. That it is cleaner, and that there are physicians present if she were to need one if an emergency arose. I was glad to hear that these women made this type of informed choice for themselves and their birth. The rhetoric that NGOs and the Ministry of Health have been disseminating for some time was evident in the words that these women chose and in their desire to protect their health and pregnancy.

Today I provided a Birth Preparation class to the women present at the Casa Materna. There were a total of 34 women currently staying at the home. Of 34 women 3 were pregnant for the first time. Of the 31 remaining 31 had a previous home birth and only 1 woman had experienced a hospital delivery. We discussed the changes that happen to the cervix, its softening and opening, and how each pain of contraction is related to more opening. I used a hand sewn model that I made two years earlier to show the changes of the uterus, the birth of a milky white babydoll, and the burgundy-chiffon umbilical cord and placenta. I acted out a laboring woman and we all closed our eyes, laid our hands upon our bellies, and deep breathed together to alleviate the intensity of our labor pains. I decided to spend some time asking women what their expectations were for birthing in the hospital, and also sharing with them what would be different here versus at home. Women shared that they thought it would be cleaner, and that if there was an emergency there would be someone present to manage it. One woman shared how she heard that many maternal deaths were due to retained placenta and that she believed that if that happened at the hospital that they would have a way to resolve this problem. I asked the one woman who had birthed in the hospital what her experience was like. She said that she thought it was cleaner [a resounding theme!] and that she liked the birth table...she felt like it gave her strength. I explained to the group, watching them lay their hands gently across their swelling bellies, how they would be brought to L&D when they have 4-5cms of dilation, about the delivery bed and the obstetric position, about the manual exploration of their uterus postpartum, and how the nurses will dress their baby and the puerperal mother uniting them on a bed at the back of the room. One mother from the group thanked me for preparing her for the differences she could expect in the hospital.

I had a major revelation as I walked out of this Preparacion de Parto class: 1) these women want cleaner births 2) they wanted access to emergency medical services and 3) when you don't know what you are missing [water birth, low-lights with guided mediation, doulas, empowered homebirth, etc.] your birth experience can be good.

Se Fue La Luz

Birth in Puerta Cabezas resembles birth anywhere in the world. Women breath hard between pursed lips, sweat beads above their upper lip, moans turn to grunts when the baby's head descends deep into the birth canal. The final pushes are accompanied by disbeleif and "no puedo mas"s. And then the head emerges, shoulders slip forward and the baby has arrived. The same languid looks are exchanged between mother and child...a regal look filled with pride and unconditional love.

The other day we had five laboring women crammed into the one room with two beds used for this purpose. Two women worked sillently through their labors, letting their fingers lite across their bellies as a contraction envolped them. Two other women struggled with their powerful contractions. I began massaging one woman's back as her contraction gripped her. One of the nursing students asked if that was helpful. I instructed her to ask the laboring woman who shook her head in agreement. The nursing student told me that she had never learned that massage could help a woman in labor. Later that evening I glanced into the labor roon as one of the older nurses bent over the same patient letting her hand trace circles across her low back. maybe I will have an influnce here.

All but four of our patients delivered on that day shift. Two of them back-to-back as the clock wound its way to 7. One woman was an adolescent girl, who often have fast and furious labors, who began pushing minutes before the lights went out [se fue la luz]. We waited for the back up generator to come on, but never heard its engine begin to roar. The labor and delivery suite without windows was pitch black. Sounds of the young woman breathing heavy and moaning as contractions built up once again filled the dark room. Two nursing students pulled out their cell phones with sterile gloves on and aimed them at the perineum. A docotor joined the team with green flashlight in tow as they hurried to force this baby out into the world. A light was finally fixed to a portable battery, and the baby was welcomed. I perfomed the newborn examination and began bundling the baby into its first clothes, as is the practice here. As the adolescent patient was being repaired, the next midwife on call had arrived and yelled 'tambikes', she's pushing, and ran into the room to help a woman who was about to have her fourth baby onto the birthing table. I wrapped the newly born baby into my arms to free the one newborn warmer, and aimed the green flashlight aloft. Four more pushes ushered her son into the world.

Number 43

...or the first baby I delivered in Nicaragua since arriving...or the first baby I delivered since becoming a CNM!

I had gone to the hospital earlier in the week. It was a day shift. As I entered the Labor and Delivery suite it was teeming with people. Currently there are a group of 8 Norwegian Nursing students here, three of them were present and accounted for, two third year Nicaraguan nursing students, two midwives, one doctor, two med students, and one adolescent patient be readied to go to c-section. She had arrived at the hospital the evening before after pushing for hours at home. When she came to the hospital she was 3cms dilated. After several hours in the hospital, rupture bag of waters, and pitocin she never progressed past 8cms, so was sent back to surgery. It has started to emerge through my time here and some research in Guatemala that women are instructed to begin pushing as soon as they experience strong contractions. Many women become quite exhausted with the work of pushing up against a closed cervix...and then end up in the hospital being wheeled into surgery. That day there were 4 c-sections and no more laboring patients, so I headed home for the day, deciding that a night shift might be more interesting, and at least less crowded.

So last night I went in to Labor and Delivery to be on shift with my friend the midwife Martina. We had a labor patient already there. She paced back and forth with uncomfortable, yet mild contractions. She was a G3P2 at 39 3/7 (for those who care!) who had been sent to labor and delivery at 5cms at 4pm, at 7pm when I checked her cervix was unchanged. The physician on call decided it was time to augment her labor and she was given pitocin (5units in 1000cc, 8drops/min) 30 minutes later she had a desire to push. I checked her again and she was 8cms with an intact bag of water. I ruptured her membranes to reveal moderate meconium (which came first the oxytocin or the meconium we will never know). 5 minutes later the mother pushed courageously and silently to the birth of her vigorous baby boy. She has two daughters already and was planning on having a tubal ligation, so was quite ecstatic to welcome her son into the world.

All-in-all it was a gentle, uncomplicated delivery. I had been feeling nervous about attending a birth since it has been almost 4 months since my last one...but I guess it’s somewhat like riding a bike, especially when you have all that excellent training behind you! It felt natural to be there supporting the woman, flexing the baby’s head, gently unhooking the two rings of cord that were about the babies neck. It’s also such a great opportunity to work with women in a surprisingly low intervention setting. No electronic fetal heart monitors, no tocometers, no IV pumps...Just a set of hands on a belly and a watch to count contractions, a handheld doppler, and a baby warmer.

One of the things that I love about being in this setting is the exchange of ideas that occurs. I have the opportunity to learn how things are done in this setting: using the partogram, charting in a different language, etc. And the midwives have the opportunity to ask me questions about birth in the U.S. The most recent conversation has been about the position that women birth in the States. Most deliveries at Hospital Nuevo Amanecer are done in the lithotomy position, that is flat on the back with legs in stirrups. I explained to the midwives that women also deliver in that position in the US, but as midwives we are trained to attend women in a variety of positions such as standing, squatting, hands and knees, etc. The nurses were so excited about this, and asked me to bring them pictures that explain how to attend women in these positions...Where is my trusty Varney's Midwifery when I need it! They explained to me that there have been women who have refused to get on the birthing table (yay!) so they have delivered their babies standing or sitting, but they wanted more instruction on this. They also say that ultimately it is the woman's choice where and how she wants to deliver.