EBB 225 – Trauma-Informed Childbirth Education with Mandy Irby, The Birth Nurse

Learn more about The Birth Nurse Founder, Mandy Irby, here.

Rebecca Dekker:

Hi, everyone. On today’s podcast, we’re going to talk with board-certified labor nurse and creator of the Birth Nurse, Mandy Irby, about trauma-informed childbirth education. 

Welcome to the Evidence Based Birth® Podcast. My name is Rebecca Decker and I’m a nurse with my PhD, and the founder of Evidence Based Birth®. Join me each week as we work together to get evidence-based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice. See ebbirth.com/disclaimer for more details.

Hi, everyone. My name is Rebecca Decker, pronouns she, her, and I will be your host for today’s episode. Today, we are so excited to welcome Mandy. But before I read her bio, I want to let you know, we will mention perinatal loss, obstetric violence, birth trauma, and assault. If there are any other detailed content or trigger warnings, we’ll post them in the description or show notes that go along with this episode. And now I would like to introduce our honored guest.

Mandy Irby, pronouns she/her, is a board-certified labor nurse with 13 years experience, supporting survivors of assault and trauma, through pregnancy, birth planning, and at their bedside during childbirth, and pregnancy loss. After her own birth trauma, Mandy quickly learned that the birth care system is not centered on human rights, patient choice, and the individual experience.

In 2020, Mandy made education her full-time career. She now teaches and supports parents and nurses on how to better center voice, choice, and physiology in birth. It’s Mandy’s mission to change birth culture so that it’s parent-centered, trauma-informed, and safe for all. When she’s not working from home, Mandy might be found at any local plant nursery, adding to her family might say, out of control house plant collection. She’s a serial craft starter and non-finisher, who loves walking her doodle puppy, and playing in the creek with her two kids. We are so thrilled to have Mandy with us. Welcome to the Evidence Based Birth® Podcast.

Mandy Irby:

Hey, Dr. Dekker. Thanks so much.

Rebecca Dekker:

Yeah, we are just thrilled to have you on here. I know you and I have been kind of talking behind the scenes for a while, so I’m super excited for our listeners to hear from you. Can you start us off by sharing with our listeners, what is a labor nurse, and what led you to this career?

Mandy Irby:

Sure. A labor nurse or labor and delivery nurse is what I found out most common in the U.S., because most of the birth centers in the U.S. give birth in a hospital. And so labor nurses are the nurses that support the labor and delivery units in the hospital. They’re nurses at the bedside, and they often do labor, birth, and some postpartum support.

Rebecca Dekker:

In other countries, often you don’t have labor nurses because the midwives are doing all of the bedside care. So in some ways, it’s like labor nurses in the United States have a lot of the similar skillset to midwives in other countries, but they’re not always granted that title. Correct?

Mandy Irby:

For sure. For sure. Well, labor nurses don’t catch babies and they don’t practice out of the hospital. Except, there are some places where labor nurses support CNM, certified nurse midwives, who do support birth outside the hospital. And I don’t think that’s very common, but I have heard of that happening, which is kind of cool.

Rebecca Dekker:

Yeah, almost acting like the midwife’s assistant-

Mandy Irby:

Assistant.

Rebecca Dekker:

… outside the hospital. And I think it’s also important to point out that although nurses don’t catch babies, it still happens, right?

Mandy Irby:

Oh, yeah.

Rebecca Dekker:

Like when the provider’s not there. You’ve caught babies, I’m assuming.

Mandy Irby:

Yeah, for sure. That’s total accidental, but it happens. And it’s funny that you say they have the skills of a midwife, because I think that some nurses would-

Rebecca Dekker:

Disagree?

Mandy Irby:

… say they do in some… Yeah, don’t align with that because they don’t get a ton of labor and birth support skills. They know like external fetal monitoring, they know a lot of the dangers that can happen and the emergencies that can happen. They’re very skilled in those. And they don’t often get as much education on, like birth support, unmedicated birth support, creative positioning things like that.

Rebecca Dekker:

So, I guess in the United States, the labor nurse often has like a deficit in their education because they’re not taught that normal, like how to support normal birth and be that hands on support person.

Mandy Irby:

Yeah.

Rebecca Dekker:

There’s not really training emphasizing that.

Mandy Irby:

Right.

Rebecca Dekker:

So, we kind of have a different structure in the United States as to other parts of the world, where nurses are there with you. And I’m not saying they’re there with you, but they are kind of running the care for most of the labor. And the provider comes in at the very end?

Mandy Irby:

Yeah, often. They’re behind the scenes or they come in infrequently to assess and do interventions, if necessary or if desired. And a lot of patients will say, “Where’s the doctor?” It’s a surprise. And they’re like, “It’s really just you the whole time.” And the doctor comes in at the end, and nurses get that a lot. And we’re like, “Yeah, the TV never shows that.”

Rebecca Dekker:

Yeah, exactly.

Mandy Irby:

It’s not in the movies. How did I get into this career? It was me following what felt right in my path. When I was in college, I thought I wanted to do science. And then I met a bunch of scientists and was like, “That’s not really me. I would like to do something with people, with more people.” People-person teaching around science, I was trying to figure out what that looked like. You’re so young, 19, 22, 21, 22.

And I was just talking with a lot of folks and they said, “What about nursing? You get to do both.” And I went into the nursing school after I started college. So I was a little later, kind of figuring out, well, maybe nursing would be it. And then it just kept feeling right that nursing was exciting, and new all the time we got to do a ton of education.

Then women’s health or perinatal nursing was obviously the most exciting. It was always new, magical, intense, and the connections that even I had with folks that I was at their birth, even as a student, I felt were really intense and really felt really good. They were really exciting and really close, and I was just the student, right?

Rebecca Dekker:

Yeah. I still remember the families I cared for, when I was a nursing student and labor and delivery. I can-

Mandy Irby:

You do?

Rebecca Dekker:

… picture their faces and yeah, I remember their stories. And I know some families and I talk with the parents I educate. Some families don’t want students in the room, but sometimes there can be really be a benefit because the student is just so involved in wanting to support you, that they can actually be a fun addition and important addition to the birth team. So, were you able to get a job in labor and delivery right after graduation, or did you have to do something else first?

Mandy Irby:

I was told to do something else. I came from a big school, a big state school that was like, “Get your skills, blah, blah, blah.” They always say, “Go to something general.” And I did, and then I quit before I even started. Again, I was trying what felt right, and going into a med surge just never felt right. It always smelled bad, it was always scary walking into the rooms. I just never felt really confident that’s where I was supposed to be.

So I called the recruiter and I was like, “Get me out of here,” And started an L&D right away in a high-risk trauma hospital. We supported a 60-bed NICU, and took all of the pregnancies, all of the high risk that was in the tri-state area. So we were kind of a hub for a lot of rural areas, and started there and was so happy that I did. And I advocate for that for new nurses as well, not to get sucked into that. You need to start on a certain unit because I just wanted to get better on L&D, and I didn’t want to get better on something else and then go to L&D. It didn’t make any sense.

Rebecca Dekker:

Well, I think that’s a good point that a lot of people recommend medical, surgical experience first, before labor and delivery nursing, or maybe even critical care. And that’s because in the United States, we often see labor and delivery as a high-risk specialty. And it essentially is, you spend a lot of time administering medications, and doing interventions and skills. Not like a freestanding birth center at all.

Mandy Irby:

Right. I was actually recently speaking with a nursing student and she said, “I’m so torn, I want to be with birth. Like I want to be at bedside, I want to be in this space. I feel like this is where I’m supposed to be, everyone’s saying go to the critical care.” But she had this opportunity to do either one. She like had a summer coming up or something. We talked about what she really, really wanted and what she really, really needed, and she ended up shadowing a midwife locally, and she got to see physiologic birth.

She got an education and an experience that most of her peers did not get. And a lot of them were getting the critical care experience during their summer internship, which is awesome and beneficial. And those nurses come in with so much education, but this person had never even considered going outside the hospital to looking for education. And I said, “Not all midwives are going to take you in. Don’t be disappointed, you might have to try a few times.” And she was so happy to have an assistant for the summer. So it really worked out great, it was pretty cool.

Rebecca Dekker:

That’s an interesting observation. So most people are getting critical care, or a medical-surgical experience, when in some ways it might be just as beneficial, if not more to also work with a midwife for a summer, or.

Mandy Irby:

Yeah, I think so. I felt so much pressure after being a nurse that, if I were at home or out of hospital birth experience, I would be confused about my role. Like, what if something happened that I felt was unsafe? What would be the expectation, I have this nursing license? Am I supposed to be still deciding if they’re in an unsafe situation? What if I was witnessing an unsafe situation? Not that out-of-hospital birth is unsafe, but I just felt like the what ifs were greater, once I had this nursing license and I had this experience. So I think as a student, before you even have the expectation in your role, you can just truly observe and truly witness it.

Rebecca Dekker:

That’s a really special time that a lot of people don’t talk about, but that internship or some people call it an externship before you graduate, can really set you up for discovering what you like and what you don’t like. And witnessing the wisdom of nurses, or in some cases, midwives who have been there a lot longer than you.

For me, my internship was actually on an outpatient surgery unit, which was a strange place to have an internship. It’s very precious to me because my mother-in-law was a nurse on that unit. She wasn’t my mother-in-law at the time, she was my boyfriend’s mom. And she took me under her wing and mentored me. And it was like this really magical summer that I spent with Dan’s mom, and just witnessing how she cared and like the art of her nursing care.

And I hold those memories really precious because she ended up dying at a young age, from early-onset Alzheimer’s. So it was like this magical time in my life. And I know not everybody gets something like that, but I’ll never forget those days, between when you have some education as a nursing student, but you haven’t graduated yet.

Mandy Irby:

Right. And there’s quickly a push to get where you need to go, start doing what you need to be doing. Also those loans don’t help the urgency to figure out what you want to do, and get into something. But how many times as nurses have we said, “I just wish my family could just come to my unit for just one shift, and just see what I do. Or like my friends that I went to college with.” I just want them to see the chaos, and the like nonsense, and intensity, and joy, and love. I had goosebumps when you were sharing your story, because that is such a connection that most people don’t get. We don’t get to share what we do with the folks that love us and that we love. They have no idea what it looks like what we do, because we can’t bring them to work.

Rebecca Dekker:

I know. And I remember as a nursing student feeling like my roommates, who were not nursing students. It was like we were living in completely different worlds. They were going to class, complaining about this or that. And I’m like, “I’m at the hospital at like 6:00 AM, taking care of people in these life or death situations.” And it felt very like I was living to straddling like two different worlds. So you’re right. I feel like a lot of people don’t really understand, those who aren’t in the nursing field don’t often get it. Another thing that I wanted to talk with you about is trauma-informed practice and education. And that’s another topic that I feel like a lot of people don’t really understand what it is. So can you tell us what is trauma-informed education?

Mandy Irby:

Sure. Trauma-informed education, for me is learning about trauma-informed care. And it’s prioritizing individuals as the leader of their own health, when we’re talking about healthcare, specifically birth care. And recognizing that our experiences as individuals shape how we see the world and how we take in new experiences. And that’s it. It’s not like this magical new way of doing things completely differently, but also it is kind of a new way of doing everything differently.

To me when I was learning trauma-informed care, getting educated, I was also at the bedside at the time, at the beginning. And it was like as a child opening a book that you thought was just this regular book, that you were going to open and every page was just going to be a picture and some text, a picture and some text. You’ve seen it before. How different could it be?

Then you open this like extra kind of thick page, and you’re like, “What is going to happen hear? This seems different.” And it’s this majestic popup page, in the middle of this book that you had no idea was going to be a popup. That’s how it felt to learn about trauma-informed care. I thought some people have trauma, probably not me, probably not people I know, but this could help with some patients at some time.

Then I start digging in and learning about it, and it is this massive topic. It is this whole new world of seeing nursing care, feeling nursing care. It really affected every part of my life. And I think as birth workers, birth professionals, it affects all of us tremendously, because we all take care of folks that have had trauma. We all take care of folks that have had previous life experiences.

We don’t know about them, we don’t have to know about them. Even if we ask about them, we’re not going to know all of them. And we have to be able to support everyone in unique ways, and be able to trust and center them as the experts in their own body.

Rebecca Dekker:

So you’re basically saying that it’s essentially holistic care because you’re really caring for the whole person, including the fact that knowing or realizing that people have past experiences that may have been traumatizing.

Mandy Irby:

Yeah. They may not be aware of how that is going to affect them in birth, specifically when supporting labor and birth in that whole perinatal period, pregnancy postpartum. There is such an openness that happens. One, a body, you literally open your body to go of birth to another human. There’s vulnerability, there’s memories that are being created, there are body memories that are being created at that time.

It’s been studied that a lot of memories are held for the rest of that person’s life. These are folks that are often the manager of the family. Moving forward, they share education about their own birth experience. They share education about healthcare, often derived from those birth experiences. They make the appointments and take their family members to receive healthcare. And the birth experience can and does shape, and has a massive effect on the relationship of the birth giver and that baby.

So, specifically in birth, not heart attack time, though trauma-informed care can and should be practiced throughout the hospital, throughout healthcare, specifically in birth. I think there are a lot of nuances and unique situations, where we have a tremendous impact on the folks that we are with in their birth experience, because their experience has a tremendous impact on them at that time. And so much is going on. So much intensity, so much vulnerability, so much openness inherent in childbirth brings up a lot of stuff from their past, either in their body or in their memory or both. That could be activation of their nervous systems, it could elicit retraumatization, and inherently birth can be a bit traumatic for us.

Rebecca Dekker:

So you’re saying, it’s not only thinking about people in terms of their past experiences, but recognizing that birth itself is a potentially traumatic event, or on the opposite empowering event? And our job is nurses is to work as hard as we can to prevent trauma from happening at the birth. And that’s not just physical trauma, but psychological. Correct?

Mandy Irby:

Right. Right, right. And in my training, I kept hearing, even if we don’t understand what’s going on or why someone is having this reaction, they have a very good reason for having a certain reaction. And in the back of my mind, I think, wow, they’ve had a whole life before I’ve known them for these hours that I’m going to know them. They have a very good reason for acting this way. They have a very good reason for, fill in the blank, helps me to really center that individual and let them guide the experience. And often the culture in the U.S. is, we always look to the nurse, so we look to the healthcare professional to guide us in healthcare. That’s not trauma-informed of birth care.

Rebecca Dekker:

Okay. You talk some in your work about consensual childbirth, and I’m assuming that’s related to this kind of trauma-informed care. Can you talk about what that means?

Mandy Irby:

Consensual childbirth is kind of a creative way of painting a picture, of trauma-informed care in the birth space, that I think maybe a little more relatable than saying trauma-informed care. We’re still learning what that is and what that means. And that’s understandable. Consensual care… I think the word consensual just elicits a sexual intonation. Often, it’s used around sexual experiences, consensual touch, consensual advances, things like that. And I think it’s just, again, centering that informed choice of the birthing person.

So I started my journey to creating The Birth Nurse as a labor and delivery nurse first, and then I had a baby. Isn’t that often like the entrepreneurs’ story? I did this and then I had a baby. It changed everything, but it did give me a different perspective. I was already an educator, getting nursing students and new grads under my wing, and educating them on the unit. I had been a nurse for years, and then I had a baby and I had this whole different perspective that I was closed off to until that point. Personally and professionally, I felt like it was this like secret experience that so many people around me had had, and yet I knew nothing of what to expect. And I was a labor nurse and I had all the privilege going into my experience.

Nurses who’ve, either been to one of my workshops, or in the trauma-informed earth nurse program have heard my story a little more in detail of that first birth experience. But I felt like I should have had everything going for me. I was giving birth in the place that I was working, and it turned out that I really felt like I was just on this ride. And I was not happy with how I was treated, I wasn’t happy with… A lot of it surprised me and I had a lot of thinking and decision-making to do after that. I became a childbirth educator after that. And I thought, oh my gosh, parents need to learn more about what’s going on. They need to know what to expect.

And I can teach a lot of things about the birth space in a hospital, but I went and got education about how to teach that childbirth ed, because that’s what people we’re looking for in their pregnancy. What an opportunity to kind of share… Here’s what the movies say. It’s not always like that, not scaring anyone, but just being real with, here are all your choices. We need to be really open and honest and frank about… There’s kind of like a standard birth track in hospitals. And here are all the other options that you have, that you can start learning about and discussing with your team ahead of time. Because that’s the cool part about pregnancy, we know the baby’s coming out. So we can plan for a lot of what’s going to happen.

Then I became a nurse educator because I was like, “It’s not just on the parents to learn how to change this culture, it’s not just because they’re not asking the right questions. I can attest.” I knew what to say and I knew what to do, and it still wrecked me a bit. So teaching nurses. In teaching nurses, labor skills, labor support techniques, peanut balls, especially. I was hearing a lot of, “But they won’t do this, they won’t do the position, they don’t like this.” And we were all speaking about our birthing families, our patients, as if they were supposed to be fitting into the way that we wanted things to be.

So, it dawned on me that we all needed a discussion around consent culture in childbirth. And even now, nurses and parents have feelings when we say obstetric violence. They have feelings around when we say, “Oh, if you don’t do it this way, it’s assault or its obstetric violence.” No one wants to be, you don’t know me. No one wants to be labeled as that, even though we know once we learn what obstetric violence is, what consensual care is. If we’re not doing that, we could be harming folks, starting that conversation by saying, “You’re either this or you’re violent towards your patients.”

It’s not opening the conversation very well. People don’t really respond well to that. So consensual childbirth is kind of a way to open the door on both sides of parents’ learning. What is consensual childbirth? What should your standards be? They should be exactly like consensual touch, consensual activity, consensual, everything else in your life. The same standards should be that or higher in a healthcare field, in a place of birth.

Rebecca Dekker:

Just because you’re pregnant, it doesn’t take your rights away.

Mandy Irby:

But damn, that is how it feels sometimes.

Rebecca Dekker:

What were some of the things that surprised you? You said you were surprised when you gave birth.

Mandy Irby:

I was surprised by how much it hurt. There’s just no real way to gauge what that’s going to feel like. I was surprised by that. And I was surprised by how little my team really cared about what I wanted. So I was having to make decisions kind of on the fly, as birth is right, as labor goes. It’s not going to go how we think it’s going to go. We’re not going to be most likely that person that you read about, that’s like, “I woke up and I was like six centimeters. And then I just bounced to the hospital, and then I was nine.” No, that did not happen.

So I was up against this is feeling different, this is scary, this is lasting longer. There was a stall situation, not really a stall, but I think I was tired and hungry, and a few things were working against my labor pattern. So I was given a lot of choices and options at that point. I was surprised by how I was dismissed by my provider, and he knew me, like we work together. And he knows that I know what’s going on and he knows that I know the options, and I expected it to feel like maybe empathy. I was missing a lot of compassion and empathy from my team. And I felt like I was ignored and dismissed when I was pretty clear about what I wanted in my pregnancy, kind of how I wanted things to go.

Even though I was being taken care of by my colleagues, which is like a whole weird thing, our relationship changed of course, forever after that. I felt like they would’ve listened to me. I felt like they should have listened to me a little differently. And I was being taken care of by my provider who knew, “Hey, these are my goal, hey, this is kind of how I want it to go.” And they were like, “Yeah, sure. Yeah, sure.” But when the time came, it was just, “Yeah, this is just how I do it, so this is just how you have to do it too, Mandy.” And I wanted to be agreeable. I wanted to preserve that relationship and to not be like wild and crazy one, who was defiant and it to a lot of self-discovery after that.

Rebecca Dekker:

It’s interesting that you said it hurt more than you expected. And then you went on this long story about how everybody dismissed you, and mistreated you, and didn’t care about you. Do you think those two things were related? Do you think if you’d been in a more like supportive environment, you wouldn’t have suffered as much as you did?

Mandy Irby:

Oh, yeah. Absolutely. it really felt like I was being taken care of by people who just didn’t really understand birth physiology. And they weren’t protective of it. They weren’t protective of my space, they weren’t protective of what I was asking for. It’s like I was going through this event that millions upon millions of people have experienced, and no one knew how to get me to reach my goals without medical intervention or more pain.

The simple things that we know, turn the lights off, give them something to eat, leave them alone, don’t come in threatening things, don’t do procedures without asking. That happened when I was there. None of those are supportive of what I was asking for in birth, which was, I just want to have this baby. And I don’t think that I need a lot of intervention to do it. There was nothing wrong. So it was really tough to demand that support when I was in that situation, and I expected to have it.

Rebecca Dekker:

Did you experience the fawning response? I’ve heard more doulas talk about the fawning response, where when you’re in a traumatic situation or you’re feeling threatened, you can fight, flight, or fawn. And fawning means like people-pleasing. Did you feel like you had that response a little bit?

Mandy Irby:

Rebecca, as a nurse, that is my response, fawning. And I think that’s common because of the power dynamics in the hospital. The top-down model, and doctors are in charge, and nurses are subservient, and then patients are even below that. So, it depends on who is the room. When my provider was in the room, I tried to do what they said, and it was really hard to advocate for myself.

I did, but I felt like pissed about it. I was like, “Ugh, this is like, makes me mad that I even have to say stop.” But I did. And I didn’t feel heard and I didn’t feel respected, and I felt treated weird for wanting something different than what he wanted. Then when he left the room, it was fight. And I started yelling and I was talking to my nurse, who was my friend. And I was like, “Don’t let him in here, that person can never come back again.” I called him names. I said, “How dare he? This is not…”

And she said, “Now Mandy,” I remember distinctly. I was like, “No, you’re not hearing me. I’m setting a boundary. That person is not going to come in, they’re not going to touch me. This is how it’s going to be.” I was so mad. I remember just like, oh, seeing red. There was also a time in labor when I asked for the car keys. And I also asked if the window in my room opened, because I would like an out. I would like to be done. 

Rebecca Dekker:

So you were looking at all the options-

Mandy Irby:

Yes.

Rebecca Dekker:

… fight, flight, and fawn.

Mandy Irby:

It was a whole process, but I was like, “Oh, I’m done. Let’s just go.” How can we stop this? How can we avoid this?. Went through all of them. But as a patient and as a nurse, I think they were different. And that’s where the weirdness comes in was I was in my place of work. Super weird.

Rebecca Dekker:

So, as you went on and you learned more about yourself and about trauma-informed care, can you talk a little bit about how you’ve served and supported survivors of assault and trauma and birth work?

Mandy Irby:

Oh, sure. It was that opening of the majestic popup book page, learning the numbers, how staggering the numbers are for intimate violence, assault abuse, realizing that it was so many of the folks that I was taking care of, whether they told me or told anyone or not. I was realizing that it was everywhere. It was in the nurses that I worked with, it was in the providers that I worked with, it was in family and friends. I just had this kind of eye-opening since I ask those questions. And as nurses, we ask and we’re often trusted with a lot of information, just by being a nurse and sitting down at the bedside. Our patients don’t tell us everything. So, I knew I was taking care of survivors without knowing it.

Since leaving the bedside, I have really loved getting to work with pregnant folks who either identified as a survivor. They identify as” I have a history of trauma and I want to prepare for my birth.” Often, they’ll be able to identify that they had a traumatic previous birth, or I’m still trying to help teach about the connection of history of assault and how that might affect your birth. We don’t like to think that has any power over us. Personally, I didn’t want to think that had any power like that was something I dealt with. It was not coming up in my daily. I was shocked at how much of an effect it had on how I processed my birth, in the moment and beyond.

So, helping folks connect that like, hey, we have this information about your history. This is what’s common in childbirth. Like I said, the vulnerability, the openness, our body memories sometimes show up. So I really love working with folks who identify that might happen. Or they don’t even identify, and they just say, “I have this huge fear of giving birth and I don’t know how I’ll ever be able to do it.” A few clients have said, “I have no idea how this baby is going to be able to come out, because I cannot see myself having this baby at all. Either way, no matter how this happens, I don’t think I can do that.”

And so I get to be the bridge for them because I’m not affiliated with their hospital or any hospital. I speak the language and I know the options, and I know creative ways to… that we can plan for and strategize around their birth, based on their history, based on their body already trying to help protect them. So that’s kind of exciting to trust that they have the answers. They are adults that have survived so well for so long, their history makes them who they are. And then we get to piece that together for how that’ll help them minimize trauma, or prevent trauma in their birth.

Rebecca Dekker:

That’s amazing that they’re willing to work with you, because I know that for some people that strong fear of birth… I’ve met a lot of people who are like, “I’m never having children because I’m so afraid of birth.” And I talk about that in our childbirth class as well, about how that’s like early common fear. And what I’ve found is a lot of people, they feel that fear wherever it comes from, previous experience or family history, and they use avoidance as their coping tactic. And they’re pregnant, but they just don’t think about the birth part. They don’t prepare for it at all, and they kind of put it off, like procrastinate. 

Mandy Irby:

For sure. Yeah, for sure.

Rebecca Dekker:

So you’ve found that it’s helpful though, for people to work through it with you through their education, like confronting their fears ahead of time?

Mandy Irby:

Yeah, for sure. If they’re ready and if I’m someone that they trust… So we talk about what we do. We go through a history and we go through a lot of the triggers is what they’re called are points of activation that can come up. And that can be really hard, but they’re also not doing it on like a printout. They’re not doing it on their own. We split up the calls and we talk a lot about the goals around the calls. We’re not trying to dismiss any past births, or make one worse than the other, or one better than the other, they’re different. Or any past experiences, we’re not trying to bring them up. But even talking about scary stuff about birth can be really hard.

So, I don’t want to minimize that work. That’s a lot of work to even just say… The list is long. It’s like 25 to 30 points of activation. And not everyone has reaction into all of them, but we’ll probably bring up the ones that folks have a reaction to. And they’re like, “Ooh, that’s one that can never…” Or they cry, or they start talking about it, or they don’t want to talk about it. So, it’s a unique spot when they’re… Often, they’ll say, “I’m not ready to do this, but I know I need to have a baby. So what do I do?”

Rebecca Dekker:

Like this baby’s coming.

Mandy Irby:

Yeah. And it’s that natural timeline that helps folks. Often, they’ll contact me at 36 weeks.

Rebecca Dekker:

Okay, but that’s still not too late.

Mandy Irby:

No. No, no.

Rebecca Dekker:

A lot-

Mandy Irby:

Not at all.

Rebecca Dekker:

… at 36 weeks.

Mandy Irby:

And when you’re ready you can take that in and be like, “Okay, let’s do this.” And we just kind of jam sessions in and they’re like, “Oh, I’m ready.” And it really speaks to their body and brains need to help keep them safe. They have a plan and they’re like, “I’m there,” but I’m not with them at their appointments. So they write their stuff down or they go to their appointment, and their providers usually loves direction.

Even if they never disclose, “Hey, I have a history of assault. I don’t want this, or I don’t want that.” They may never disclose that to their provider. They go in and they’re like, “Hey, these are the things that are going to help me feel powerful, strong, and confident in my experience. I want to be treated this way, or whatever they come up with.” Their provider’s like, “Awesome. Can I put that in your chart?” I would love direction to help you work through what you need to work through, and be there and help you be successful. I would love that, and they’re really surprised by that.

Rebecca Dekker:

How did you learn how to teach childbirth education through this lens, and how to work with survivors? Did you go through trainings, was this self-taught?

Mandy Irby:

Yeah, trainings I started with Lamas, was the training that I took for childbirth ed, was able to write some curriculums after that training, which I thought was really great training. It taught me how to teach adults, which is different and unique, and I thought was really beneficial. And then also crosses over to teaching nurses because nurses are adults. I’m shocked by how much labor nurses we don’t know childbirth ed. So that was embarrassing and a little humbling.

And then finding the holes in nurse education because I was a nurse and I was at the bedside, and I was with nurses. I worked with a large team, I was able to discuss with them, I was able to teach them. And I took Penny Simkin and Phyllis Klaus’ When Survivors Give Birth, and it was like a week training intensive, in-person training for educators and professionals. I’m not a counselor.

I don’t want to be a counselor, I don’t plan to be a counselor, we don’t do counseling. But we do some processing, and I am able to do… with my nurse education and nurse background, able to who advance those listening skills, and those education skills, and not give diagnoses, which is wonderful. But just pinpoint each person’s unique experiences and how it comes together in themes that are often seen, and the fears around childbirth. Then coming up with a plan is just of birth planning. So a lot of that came from When Survivors Get Birth. They have a book and then they do classes in Seattle.

Rebecca Dekker:

That’s awesome. I love how you were tying together your nursing education with childbirth education, and then survivor education as well. I want to talk with you a little bit about birthing positions, because I feel like that has a lot to do with choice and consensual care. And I know from reading the research about birthing positions and having published… We have a signature article on that EBB at ebbirth.com/birthingpositions, that although providers and nurses may be okay with you pushing in a certain position, when it comes to the actual quote delivery, they often expect you to be in the provider’s position of choice. I know you’ve been talking a lot about this on TikTok, and getting some pushback. Can you talk a little bit about how important it is for people to give birth in the position of your choice? Some kind of your journey in sharing about this, and the feedback you get.

Mandy Irby:

Yeah. And what the hell, Rebecca. Can we talk about this?

Rebecca Dekker:

Yes, we can, Mandy. All right, get on your soapbox. We’re ready.

Mandy Irby:

Can we talk about this?

Rebecca Dekker:

Yes, you’re warmed up. Let’s go.

Mandy Irby:

I know. Gosh, you got me right in the spots today. It’s great. We talk about this on TikTok because it’s like the Venn diagram of childbirth ed online. It’s what I love to talk about. I love sharing about birth positions. I think it’s really powerful, we can get really creative that way. I go to labor units and teach hole units about peanut balls. You would think like, how could we talk about peanut balls for three hours?

It just shows that nurses aren’t getting this education and they’re so hungry for it. They want to help folks, like race that cesarean clock. We all feel everyone’s on the second they get in the hospital. And nurses are like, “Ugh, up the pit, break the water. I don’t know what else to do.” They have so many skills that they can do, they don’t need an order for.

So they love learning about positions often, or at least that topic. Parents love it because it’s something they can do. They can learn a lot about before they get in, and they can advocate for themselves when they’re in labor that way. Then it’s the Trojan horse of consensual childbirth, or trauma-informed care without saying this is trauma-informed care, because that doesn’t mean as much. I get to model and discuss, choosing those positions with pushback.

We get to discuss the standard care that you receive in the hospital. And all of these other options are totally within your realm. Totally something you can ask for. And it’s a whole back and forth of nurses being like, “Yeah, unless there’s emergency,” and the parents being like, “Yeah, but what about if I have an epidural? I was told I couldn’t move at all.”

A lot of these truths are coming out on social media, and I really, really love that platform for it. I was never a social media person took me years to figure out emojis. And I felt like I was too old for or TikTok, but that’s where folks are talking about their experiences and they’re sharing. I don’t feel like I can help patients because our doctors are so stirrup ingrained. So yeah, I do. I know you want the T. I get a lot of pushback from nurses and OBs on social media.

Rebecca Dekker:

When you’re sharing on media, like empowering ways to how to tell people you want to give birth in the position of your choice, and giving examples of you give scripts and stuff like that, right?

Mandy Irby:

Yeah. Well, I talk about the most recent crap I got from an OB was someone in the comments. I don’t know them, but they are on social media as doctors so and so, and they’re an OB. And she said, “It’s really harmful to call stirrups restraints.” That’s fear-mongering, it’s not true, it’s not like we’re holding anyone down. You shouldn’t call them that.

Rebecca Dekker:

So you’ve been like calling out the use of stirrups as a patient restraint, medical restraint.

Mandy Irby:

Yes, it’s a medical… Yeah, yeah. Have you ever been in stirrups?

Rebecca Dekker:

Appointments, yeah. I guess at my first birth, but I think I’ve blocked it out of my memory.

Mandy Irby:

Okay, sure. So that says something. But not definitively, we’ll have to do the blind study. But being pregnant, no matter what pregnancy you are, no matter what size you or your baby is, being pregnant, you have weight on the front and weight on your core. So, you ever lay down and you’re pregnant, or try to tie your shoe, or try to get up from laying down on your back, sometimes for me it felt like I was a turtle. Like you had to roll over to just get up. There’s no like activating your core, and just standing up because it changes your body. So, you put someone on their back, who’s pregnant. Then you put them up in stirrups. So their legs are almost above them, in stirrups without that core function, and then you take half of the bed away. It’s really, really difficult to move for yourself. It’s really difficult-

Rebecca Dekker:

Or get out of it.

Mandy Irby:

… to change your position or to get out of it. Necessarily, it’s not termed stirrups, but I think that it is something that we should discuss because it can be really harmful. It can hurt. It could damage nerves if they’re in there for too long, or if they’re positioned wrong, they’re not made for everybody’s size.

Rebecca Dekker:

I actually was reviewing the latest research on birthing positions, and the latest meta analysis on this said that stirrup lithotomy position with stirrups is so harmful, that we’re not even going to include it in this meta analysis. We’re not going to use it as like control or comparison, because it’s so bad.

Mandy Irby:

Because it goes the other way, right?

Rebecca Dekker:

Yeah. So-

Mandy Irby:

It’s not a control. It’s actually harmful because it’s not-

Rebecca Dekker:

It reduces blood flow to the baby, as well.

Mandy Irby:

It reduces blood flow to both parties. It’s not helpful for getting a baby out. You can slow down getting a baby out.

Rebecca Dekker:

Why it reduces blood flow for those of you who are listening, who aren’t in the medical field, it’s because you’re pressing all of that weight on that abdomen and the pregnancy onto the aorta, which is what delivers the oxygen to the lower half of the body, including the uterus and the baby.

Mandy Irby:

And it can harm the birth giver’s nerves in the legs and the hips.

Rebecca Dekker:

Especially, if you’re in it for hours-

Mandy Irby:

You’re in it for hours.

Rebecca Dekker:

… which you’re in it for hours, which I’m pretty sure I was for three hours.

Mandy Irby:

Yeah, same. And this is not a personal experience, everyone should learn from my personal experience or your personal experience, these are all in studies and written about for decades. This is all information that we all have access to and we’ve all had access to it. And I think it’s barbaric that it’s still being forced on folks and what it does, as labor nurses, what we see it does regardless of the restraint, whether you want to call it restraints or not, because you said it restricts the blood flow to the baby lowers BP of the birthing person.

It’s about time to have a baby. It’s a stressful time for the baby often, you want to do shorter pushes sometimes when that baby is like, “Oh, I just need a little break.” Their cord is being squeezed, lots of things are already happening. Then you put them on their back in a position that actually causes problems. And then it’s an emergency that you need to fix and save them from. So it’s kind of like the perfect situation in a hospital when you’re like, “Oh, everything’s going fine.”

Rebecca Dekker:

And then when people say, I don’t want to be in this position, they’re gaslighted and told, but I have to do this for the safety of your baby.

Mandy Irby:

For your baby. Would you want to harm your baby? Which is false, it’s gaslighting, but it’s also lying because it’s actually the opposite of doing that for the baby. So it is, I think at this point, truly just a provider preference. And it does feel like it’s a power move because of all the information we have about how non-evidence based it is, how it’s not helpful for the general public. Straps were not meant for childbirth, they were meant for urogyn, surgery, and postpartum repair.

Rebecca Dekker:

It’s funny, one time I was doing a talk at a local brewery. They were having, it was called I think Suds and Science or something like that. And they had me come talk and I was trying to think of a good example of maternity care and how screwed up things are. And so, what I did is I asked for a male volunteer to come up and he had to lay on a table at the front of the room and put his legs like in the stirrup like position. And I said, “Okay, now poop.”

Mandy Irby:

Yeah.

Rebecca Dekker:

Let me shine a light on your ass. And everybody was just like, “Yeah.” I mean, I think I made sure he got a prize afterwards because that’s very… But how different is it in front of a crowd of people-

Mandy Irby:

And it’s really scary-

Rebecca Dekker:

… birthing room or at a brewery, it’s scary either way.

Mandy Irby:

It’s scary either way. And it’s scary when that person is saying, “No, you have to do this because it’s best.” And don’t you think I would know what’s best? It’s all kinds of messed up. It’s all messed up. So I think it’s a great way to open the discussion and it happens so frequently still, it’s astounding.

Rebecca Dekker:

This has not gone away because some people are like, well we don’t use stirrups anymore.

Mandy Irby:

Whatever, it’s everywhere. And I think nurses have a responsibility to not cover up these stories by saying, “We don’t do that anymore.” That’s amazing that you don’t do that anymore. But what I want to hear from nurses is, how did you get there? Because it’s not helpful to hear that your hospital didn’t do that anymore. When it’s helpful is in a community, maybe like Facebook group, or community group where parents are. Tell them, “Hey our location, we don’t use those anymore because they’re barbaric, they’re not evidence-based. And our whole practice has changed. Instead, we do this, this, and this, and this.” That’s awesome, parents want to know that.

Nurses, you are silencing the thousands and thousands of hospitals that still do one, use them and two, force their use. So instead of, “We don’t use those anymore, how could you ever use those?” I do think it’s helpful when other countries do speak up about it because it normalizes it, when every Australian nurse in my comments is like, “What are y’all doing? We don’t use stirrups except for urogyn procedures and postpartum repairs when necessary.” UK, same thing.

I think that is helpful. For U.S. nurses, I think, oh we don’t do that anymore. Finish the sentence with, “We fired all of our providers that did it and we don’t tolerate that. Or, we had a whole program that lasted 18 months on education, change in policy, practice changes, we observed, we tracked. What are the things that they did to change behavior? Because it’s a huge behavior change, obviously it’s not happening naturally. They had to have done something to do that.

So I think that’s the most helpful information when we’re discussing, oh, it’s not everywhere, it’s in enough places that I have millions of views and thousands and tens of thousands of comments of parents saying, “They told me I could push in any position I wanted. And then they forced me on my back physically, or verbally, or both. That shouldn’t ever be happening anywhere. It’s still a huge problem.”

Rebecca Dekker:

Do you have a brief script you could share for our listeners who are worried that maybe they’ve said, “Oh yeah, you can push in whatever position you choose.” But then you get to the… your baby’s about crowning and about to come out, and the provider’s like, “Get on your back now or lay back right now.” What is something that a parent could say?

Mandy Irby:

I think the work happens in pregnancy for the birthing parent, the pregnant parent, the pregnant person. That work is, I don’t want to do this, one, you don’t need a reason, but you’ve been on TikTok, you’ve heard that that happens. And that just doesn’t feel right for me, whatever your reason is, you don’t need to share the reason. But if you do, share the reason why you don’t want to do that, learn about other ways. So view birth in other positions so that it’s totally normal.

So that your body has that, your mind has that memory, and you’re just like, “Yes, this is happening. Yes, this is how we do it because I’ve seen it.” Because if you just go with what you see pictures of, all pictures on Canva are on your back in stirrup positions, all over, we see that. So train your brain, that it can happen in other ways. And then now, one way to do it, I’ll share some language in just a second, but anyone that’s supporting you.

Of course there’s privilege to having others in your birth space with you, and I know sometimes it’s limited at this point in COVID, if it is limited, if anyone can be with you that you know and complain with ahead of time, they need to be told and educated on what to do in that situation and how to advocate. And if you don’t know them ahead of time, then hopefully you can share with your nurse, how to support you and how to help you not turn on your back at the time of pushing. Often, that happens when they want to check your cervix to make sure your 10 centimeters and then that’s how folks stay on their back.

Rebecca Dekker:

Oh, can you get back in this position? I just need to check you. And then they don’t help you out of that position.

Mandy Irby:

And then you’re that turtle right on your back. And so it’s really hard to do it yourself. So having a game plan around that, knowing that there’s that exam, that’s going to be requested of you can make that choice. And then that blows people’s minds, “Wait, I don’t have to get checked?” That’s a hold in discussion of whether you want to get checked, or you can be checked on your side, or you can be checked on hands and knees, whatever position you’re in. You can ask if you can be checked in that position.

And then the folks around you should really be kind of your wall around helping you into and out of the, on your back position. Or even in the stirrups position because no birthing person is put their stone stirrups up and putting their own legs in their stirrups. Other people are doing that. So that’s when we have to draw the line of, I will not tolerate others putting my legs in stirrups.

That is not putting the responsibility on the breathing person. This happens against people’s will all the time. That is not your fault as the birthing person, if that happened to you and your listening, that is not your fault. Going forward, I want folks to know it’s really hard for the birthing person to advocate at that time for themselves, physiologically, emotionally, your brain is in a different space, doing the work of giving birth and pushing, that’s the transition that opening up, getting ready to have this baby. So it’s the responsibility of the folks around you.

Rebecca Dekker:

Of the support team.

Mandy Irby:

And then they can just say, “Nope, they said this position’s good.” Or, “They’ve been in this position, and they told me they would tell me if they needed out of it.” So like your partner, your nurse can say, “This is effective, I think they’re going to stay like that.” And they teach nurses-

Rebecca Dekker:

There’s the whole option of just not getting in the bed for the birth, which I know hospital staff hate. But you know, I know it can happen because I’ve seen plenty of pictures of people birthing on stools or squatting next to the bed or whatever, and not getting in the bed for the actual birthing.

Mandy Irby:

Yes, that’s… Ugh, I always get so much for that. But yeah, I asked a local OB. I said, “Hey, I taught this in a class the other day, but what do you think about if someone brought a gym mat and prepared to give birth out of the bed and never wanted to get in the bed?” And she was like, “Ew, the hospital floor is so dirty.” And I was like, “That’s your first reaction?” And she was like, “Yeah, that’s gross.” And I said, “Okay, okay. So imagine we put a sheet on the floor, we make like this little area sheet on the floor.

Rebecca Dekker:

Sterile flooring.

Mandy Irby:

What do you do? Because it could be slippery. And then pad, and then pillows, and they’re like, “Oh, well, I mean, if I don’t have to sit on floor and they’re not on the dirty floor,” it was all about hospital floors are dirty, had nothing to do with how a baby would come out or how they could possibly do that. This person obviously knew how to support birth in a lot of different ways. And she’s like, “Then I guess I don’t think I’d have a problem with it.” And I was like, “Everybody, everybody, you don’t have to get in the bed. And I’ve asked an OB.” And they were like, “Oh, that opens my mind up to a whole new bunch of-“.

Rebecca Dekker:

There’s nothing magical about the bed. Although each hospital probably spends how much on each bed, 30,000, 20,000?

Mandy Irby:

They’re expensive, yeah, they want to use them.

Rebecca Dekker:

They’re expensive, these beds that break apart and get all these fancy positions. There’s nothing magical about it. You can give birth in a tub, or in a stool-

Mandy Irby:

On the toilet.

Rebecca Dekker:

… or on the floor-

Mandy Irby:

On the floor.

Rebecca Dekker:

Or like standing.

Mandy Irby:

Folks that want an epidural, you’re going to be in the bed.

Rebecca Dekker:

Yes, that’s true.

Mandy Irby:

But not always lost, and you don’t have to be on your back.

Rebecca Dekker:

Yeah. Side lying is a really great position from the research about pushing with an epidural so-

Mandy Irby:

Yeah. Can be protective of your perineum, I was just listening to your perineum podcasts that are super interesting.

Rebecca Dekker:

Yeah. So we have covered so much today, Mandy, and our time is up. How can our listeners follow you and your work? Do you have any projects coming up that you want to share about?

Mandy Irby:

Oh sure. You know about this because you and I have talked, but I will be announcing for nurses. Some changes going on with trauma inform birth nurse program. We have that group called the Nurse Circle, the private nurse group associated with that program and it is the only program for labor and delivery nurses on trauma-informed care. And it’s also by labor and delivery nurses. So that’s really exciting.

That is going to be open again this spring, and we’re going to announce some changes for that. That’s going to be bigger and better. And then I’d love to see everyone on Instagram @thebirthnurse. And I also have a podcast which sometimes I forget to share about, but I have a podcast that I co-host called the Pulse Check Podcast. It’s for healthcare professionals, but we find that consumers and professionals benefit from the discussions there.

Rebecca Dekker:

Awesome. And you are also on TikTok as thebirthnurse and have a thriving community there and tons of views and The Birth Nurse official on YouTube. So I’m glad that you shared about your trauma-informed nursing program. Because I think that’s so important, it’s often left out of most nursing education programs. So I highly encourage nurses in the labor and delivery field to go check out Mandy and Mandy’s programs for educating nurses on trauma-informed care, and providing support to nurses, many of whom are burned out and feeling that burnout from the pandemic and from other things as well.

Mandy Irby:

Yeah, it’s so supportive because of the moral injury and your own trauma. We’re often in abusive work situations. So we’re there with you in that, it’s nuanced, it’s layered.

Rebecca Dekker:

Thank you Mandy so much for sharing all this info with us today. We appreciate you coming on the podcast.

Mandy Irby:

Ah, thanks for this discussion, Rebecca, and thanks for having me. Good to talk with you.

Rebecca Dekker:

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