Affirmation for a New Year

Having been nearly two years since I purposefully exercised, I went to a sunrise yoga class. Pre-sunrise, actually, so that my sacrifice is clear. Twenty-five degrees and dark, and I willfully got up out of bed and dragged my creaking 40-yet-feels-like-90 year old body to a yoga studio.

And like the sun rising over the horizon, I eased right back in. Years of practice and teacher training came back seamlessly. It wasn't easy, for sure. But I did it.

And the one thought that kept coming to me as I moved from one pose into another was: Always have faith in your body.

I felt like one of my laboring moms, realizing the strength and depth of resource that we all have within ourselves to give birth -- to a child, or to our new and improved selves.

Happy New Year, to all my friends and family, to my Facebook and blog readers, and most of all to the women and couples and children who have allowed me to participate in the birth of their families. May I never lose sight of the privilege I've been given.

To Empower...? Maybe not!

Recently, a friend (not a birth professional, because I do interact with a whole slew of people out there who have fairly normal jobs with predictable hours!) was discussing her work with me. Part of her work, she felt was "to empower people" as much as she could.

It's not the first time I've heard the word empower used that way. But I look at it the way I look at women who say their OB's delivered their babies -- Who is empowering whom? And with whose power?

As a doula, I don't have any special powers or magic dust. I am not a supernatural force field against a c-section or traumatic birth. And I don't have the ability to empower. I relish helping women feel safe, relaxed, and informed; and it's within that framework that I hope they can tap into a strength and faith that is all their own. I can't empower them any more than I can push their babies out for them.

Tricky stuff, language. And words often reflect our cultural, social, or ideological beliefs, as seen in the fact that many women don't refer to giving birth to their babies, but their babies are delivered. Delivered by whom? By the doc on call.

Doulas, in their websites or marketing strategies often state that one of their jobs is to empower women. I feel very strongly that this is not what I do.

--An Unmedicated VBAC? Really? --Yes, Really!

My client was underneath a heated blanket, her naked newborn boy snuggled on her naked chest. She was marvelling at how special the immediate skin-to-skin experience was, particularly because she had delayed skin-to-skin with her first, as she was born by c-section. This was one of her largest motivators in aiming for a VBAC.

"That was amazing," she said. "I can't believe I did it."

"Not only did you do it," chimed in the attending OB from where she was counting instruments, "but you did it unmedicated. Almost no one can say that."

My client's VBAC certainly is a personal victory; given today's VBAC climate -- despite the NIH findings that a trial of labor after a c-section is actually safer than a repeat c-section -- it is a political victory as well. But the OB's comments are sticking with me because my witnessing of unmedicated VBAC seems to be the direct opposite of hers. I have attended about a dozen VBAC's in the past year, and all but 2 did it unmedicated (and those two had c-sections, one after a trial of labor, the other with no trial of labor).

Looking at older (2005) statistics from the MA Department of Public Health, epidural use was between 60-70 percent at the hospitals I frequent the most. Whereas those who work on L&D have seen probably thousands more births than I ever will, I think I have been a part of more unmedicated births because I am trained and experienced in specific, non-pharmacological, emotional and physical comfort measures that provide pain relief, and because I provide home support -- where that is the only option available.

My client had been admitted at 8cm, and was showing some of the "classic" signs of transition. All kinds of things were coming out of her mouth. Her sentences, all stream-of-consciousness and irrational, generously peppered with various forms of the word "f*ck," were basically amounting to the fact that she didn't want another single contraction, and that she wanted to put on her clothes and go home. When she said she couldn't figure out if she needed to pee really badly or if she needed to have a bowel movement, she began asking for an epidural.

When the OB said she was dilated to "9 and a lip" (a lip is a bit of remaining cervix that has not dilated), all my client heard was that she wasn't 10 cm, and her request for an epidural turned into a demand. Feeling the arc of this birth unfolding, I did exactly as I had promised her I'd do if she asked for an epidural -- talk her out of it. I explained to her that all the pressure she was feeling was the baby moving down through her pelvis. She resisted, saying again that either she wanted to put her clothes on and go home, or get an epidural. The nurse said, "OK, if you're sure an epidural is what you really want." She said it with great hesitation, probably because she knew this baby's birth was not far off, and because by the time anesthesia would have gotten there and placed the medication, the baby would have been born already. And probably because she didn't know what else to say, other than the words she needed to order an epidural .

Knowing that pushing would be a relief, as it is for many women, I said to her, "Pushing and getting this baby out is the best pain relief you can get." I asked the OB quickly, "Can she push past the lip?"

The OB took a deep breath and carefully considered my question, and I wondered if she'd ever been asked that before. I could practically see the light bulb going off in her head before she said, "I don't think that pushing past the lip will interfere with her progress at all."

My client needed convincing to push, so I suggested she push just to try it, and see if it helped any. The lip was anterior (towards my client's pubic bone), so I suggested she get back on hands and knees so that the baby's head would finally press out that lip. She pushed with the strength of an army of men, and 20 minutes later, my client was holding her baby in her arms.

What would have happened if my client had gotten the epidural, assuming that there would have been time to place it? Her baby was coming with such force that it is doubtful an epidural would have slowed the contractions, especially at 9+cm. For the same reason, I can't imagine it would have drawn out the pushing stage into anything long and exhausting, as can also happen with an epidural. She would have had a happy and healthy baby, and she would have done so via VBAC. And retrospectively, perhaps she would have been just fine with getting the epidural, especially when she'd get to the part of the story where she would describe the amount of pain she was in. It all would have been fine, probably, but I am thrilled that my client does not need to reconcile her goals for her birth with its outcome.

Lesley Everett, a doula in Montreal, just led a doula training for L&D nurses. The snippets of what she shared from that experience are encouraging -- many of the nurses who attended expressed some layered frustrations; not only do they not have the knowledge on how to support women who are laboring without an epidural, they have too many patients at one time to provide the focused and concentrated work of unmedicated labor support. Combine that with the fact that the spectrum of emotions and behaviors that unmedicated women present with can be pretty darn intimidating if you are not accustomed to it. What results is a lack of practice, which leads to lack of confidence, which leads to a lack of practice.

I am heartened by Lesley's work, and I'm hoping that my client's birth experience prompted some out-of-the-box thinking for the hospital staff involved, a gentle reminder that babies are born in hundreds of ways, as long as the mothers have knowledgeable support.





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See What You Can Do? (And you're not even in labor yet!!)

I have a client due now-ish, someone whom I've felt a sweet connection to from the beginning. The stakes are high for her, as she wants to have a VBAC, and she deeply questions the necessity of her c-section a few years ago.

This client, like many VBAC women, has a "supportive" OB -- who has scheduled her repeat c-section for one week past her due date. And like many VBAC women, is under a tremendous amount of pressure to go into labor spontaneously and has spent many hours fretting, losing valuable sleep as she worries about how to get labor started.

She has armed herself with tons of information, so she knows that VBAC theoretically has less inherent risks than repeat cesarean. She understands that a healthy, spontaneous labor can begin at 42 weeks, which is 2 weeks past a due date. She understands the details of her own c-section and why she is particularly low risk for possible VBAC complications. In fact, a lot of this information came from her supportive OB -- the one who scheduled her repeat c-section.

She understands that hospitals have administrative protocols, so perhaps that is the sole reason why her surgery was scheduled. When the hospital sent forms for her to sign, her OB said, "Oh, don't worry about those things!" But her due date is approaching, and the supportive OB is now saying "Hopefully we won't get to that date, so let's not worry about it now."

But she is starting to worry, because that repeat section certainly becomes more possible with each passing day.

And then yesterday she had high blood pressure. She's a pregnant woman at 39 weeks, moving triple her usual blood volume and supporting another life inside her own body. She's working hard. She's also caring for a toddler. And she's anxious about her baby's upcoming birth. Of course she's got high blood pressure.

Her OB's solution to high blood pressure is to make her not be pregnant anymore (and notice that what my client has is high blood pressure, not pre-eclampsia, and it is important to know the difference). She has swept her membranes, and wants her to return in 24 hours for another blood pressure check and for another sweeping "if this doesn't work." And then the next step would be for an induction, if her cervix is favorable. And if not, c-section.

Between now and then, I gave her a few suggestions. She has been avoiding salt, but I explained to her why the body actually needs salt and so suggested that she use a little sea salt on one small thing on her plate. I also suggested soaking in epsom salt baths, maybe 2-3 times before she returned for the blood pressure check. I also suggested that she reach out to her ever-loving network of family and friends who have offered to help her when the new baby comes and tell them she needs their help NOW, to care for her daughter, to cook up a few meals, to run some errands -- because nothing is more important right now than putting her feet up, resting, drinking lots of water, and putting to use those very same meditation and visualization exercises for labor that she's been practicing for weeks.

She returned to the OB, and guess what. Her blood pressure was down. Not only that, physically she felt better. She thanked me for the suggestions, but I told her it was her body, and that she had done it. Just wait till she's in labor.

What's a Good Doula to Do?

Recently, one of my clients went in for a c-section after a trial of labor. The nurses could see how much support I was providing my client, who was definitely more than panicked by labor. I'd say she was bordering on hysteria at times, but with guided visualization and breathing exercises led by me, she would calm down.

When the nurses brought scrubs for the husband to wear into the OR, they gave me a set, too. "She needs you in there," they said.

I went into the bathroom to change, and I could hear the anesthesiologist saying no. Rather than put the scrubs on, I came back out. I asked the nurse "No go?"

The anesthesiologist looked at me directly -- and not unkindly -- said no, I could not go in. She even said she was sorry, then explained to my client "There's just so little space in the OR, and with both your husband there and your doula, it will be too crowded."

I have to admit that I was disappointed, having never been in the OR yet, but I readily accepted her decision. Doulas almost never go into the OR. More importantly, I felt like my client had no expectation for me to be there, and she was fine with it. I told her I'd wait in her room, that I'd be there as soon as they brought her back in, and that I couldn't wait for her to introduce me to her baby.

Soon it was just me in the room, and I was tidying up my client's belongings. Another nurse came in. "Do you still have the scrubs?" she asked. "Put them on, because I think you should go in there."

I told her that the anesthesiologist had already refused me (what I learned in training was that it was the anesthesiologist's call, since doulas and partners would need to share the same space with that doc).

She shook her head. "I'm the OR charge nurse" (or whatever her title was...), "and it's no one's decision but mine, and your patient needs you."

"Is she having another panic attack?" I asked.

"No," said the nurse, "but if she does, you're the one she responds to."

Truly, I felt that my client and her husband were fine, even relieved to choose a c-section (and they did choose it). I said to the nurse, "The anesthesiologist looked right at me and told me no."

"But it's my call," she insisted. "They won't give you a hard time, they'll give me a hard time."

Had my client been unravelling, perhaps I would have reconsidered -- perhaps. But doulas walk such a tough line in the hospital; I'm only as good as the doula the staff has dealt with just prior to me, and whatever I do sets the mood for the doula they encounter after me. And doulas have to work hard to earn the respect of OB's, more often than not. Ultimately, I decided not to go.


What would you have done?


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Happy Mother's Day! (Or What Goes Around, Comes Around)

Often I've heard people scoff at Mother's Day, calling it a "Hallmark" holiday, just another opportunity to increase sales.

But on a personal note, having lost my mother when I was only 14 years old, I spent many, many years yearning to send my mother a Mother's day card. I did send cards to the mother-figures in my life, and thankfully I've had many of them, including my mother-in-law; but nothing ever truly filled the void.

My mother died when I was so young, and consequently there are many things I did not get to experience as a daughter. As I grew older, I had to rely on my imagination as much as my limited memory to know what it was like to have a mother.

But then Soledad came into the world, and I knew -- the overwhelming love, the sudden obligation, the inextinguishable need to protect. This is what it is like to be the daughter of a mother. This is how my mother loved me; there are no more doubts.

And magically, (and perhaps coincidentally, since I was gone for the better part of 4 days attending births this week) these are the paintings my daughters made for me on Mother's Day.

The one on the right was made by my oldest daughter. On the back, she wrote: "I remember being in your stomach!" The one on the left was made by my middle daughter. She handed it to me, and I assumed she was following her sister's lead as she often does, painting herself in my belly. "Mama," she said, "this is you inside your mom's belly!"

What goes around, comes around.

Sunday, Three Years Later

I wake up to my phone ringing at 6AM. My client is in labor, experiencing strong contractions every 7 minutes.

She had called me three years earlier, also on a Sunday morning. Her contractions were mild, but steady, about 10 minutes apart. She went to church, ate lunch, went for a walk. I joined them mid-afternoon, and she was admitted to L&D at 8cm. She began pushing once fully dilated. And pushing. And pushing. And pushing. She pushed for 2 hours, and the baby budged not at all, and in the moments before dawn, she delivered her baby via C-section.

That was the very first birth I had ever attended. I have never forgotten her, always wondering if my inexperience contributed to her c-section.

And some thirty births later, she sits on a birthing stool, leaning on her husband for support, one hand on a squeeze bar, the other hand powerfully gripping mine. In the expanse of the room, we huddle in the corner, hospital bed pushed out of the way. Her OB catches her baby while half-crouching, half-lying on the floor. Via a well-placed mirror, the mother and father watch their beautiful daughter come into the world -- an unmedicated, spontaneous, vaginal birth after cesaerean -- and all the wondering is gone.


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Three for Three

The last three births I've attended have been c-sections. And you know what?

It's OK.

Of course, all three pairs of moms and babies are utterly fine and healthy, all recovering normally with no complications, but that's not what my focus is. In broad strokes, I think the reason why I'm not disappointed is because all three moms had choices. All three went into their births so informed about their options, about the common interventions suggested even when a labor is progressing normally, and about typical complications in late pregnancy and labor. They questioned their care providers, not for the sake of being contrary or dismissive, but because they wanted to to be fully participant in their births and not have their births "done to" them.

When the course of their births turned in the direction of c-section, we took a look at every alternative and weighed options. And I know that later, when they review their births either a week from now or a year from now, they will have no regrets about avenues unexplored.

The Mother-Blame Game

Reading blogs can be a little bit like spreading rumours in high school -- there's a story, and the story changes with each person who passes it on, and the story you end up with is vastly different from the one you started with. Despite this, someone runs with this end-product story, believing it to be truth.

Take, for example, the story of a woman in a Chicago hospital who was given the wrong baby to breastfeed and is consequently suing the hospital for negligence. I heard about the story from this article, several hands later, which tangentially asks, "Would you breastfeed someone else's baby?"

That question, of course, is misleading -- because the woman in Chicago was never asked that question.

And the answers are heartbreaking and judgemental - the woman who was given the wrong baby to breastfeed is accused of being a negligent mother for not recognizing her own baby and for choosing not to room-in with her baby. Both the article and the comments review the history of wet nurses and wonderful stories of orphaned babies being fed by a community of breastfeeding women, and so her character comes under question -- perhaps deep-down she finds breastfeeding really disgusting, and why can't she be generous enough to share her breastmilk with another baby in need? Someone even suspects that she's a money-grubber, trying to get rich off the situation.

Acknowledging that we are a litigious society, which in part is the reason for high and unsustainable medical care costs, is important. Important, but far from the point. Suing the hospital for negligence is one of the options that exists among other formal, punitive, and ultimately corrective options. And clearly the hospital needs to be accountable for an identification error whose consequence could have been far worse -- the woman could have taken the wrong baby home, or medication could have been given to the wrong baby (and she's suing for $30K, by the way, which in the grand scheme of a hospital's budget is not a whole lot of money).

But how quick we mothers are to judge another mother. And I hear this kind of judgement, and the ensuing cycle of mistrust and guilt, more often than I like in the birth and parenting world -- between mothers who feel as though their births are being looked at critically by another mother, or their choices in how to feed their babies are being evaluated by another mother, or a mother who makes assumptions about another mother who is having a harder or easier time than she is.

What I have learned in parenting 3 children, in attending birth after birth after birth, and in listening to mothers tell their stories about motherhood, is that there is no singular, right way to go about these tasks. Despite so many options, and so many, many mothers out there, motherhood can sometimes seem like a very lonely place.

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Why Choose a Midwife in Massachusetts?

Here is a fantastic video that wraps up so succinctly all the reasons why Massachusetts MUST pass a midwifery bill. This isn't about women craving an indulgent birth experience, but it is about giving pregnant women choices about their bodies, their babies, and their health.

"Congratulations! You're in labor!"

I've been thinking lately about a client, whose story goes something like this.

Something felt "different" when she was 36 weeks and 6 days pregnant, different enough to call her OB, who then asked her to come in to triage. She saw some bloody show, and it was more red than what she expected.

She was placed on a monitor for about 60 minutes or maybe a few more. It indicated not only a healthy fetal heart rate, but that she was having contractions every 3 minutes.

"Really?" she asked. She felt no contractions, or anything that she imagined contractions would feel like.

"Yes!" the nurse confirmed, teaching my client how to read the strip. "You're in labor! Congratulations!"

Since her contractions were three minutes apart, she was encouraged to admit herself to L&D, since she was going to have a baby that day. A check of her cervix indicated she was 3cm dilated. "Plus, it's quiet here today," she was told. "Perfect day to have your baby."

My client and her husband had left their home in the usual weekend disarray. And because they were not anticipating a birth at 36 weeks and 6 days, their home was not quite ready for a baby. Thinking that her time was limited, she and her husband decided to go home, to get as much done as they could before the early arrival of their baby, which, according to the fetal monitor, was imminent.

After getting home, they cleaned the kitchen. They prepared some dishes for the coming week, when everyone had warned them that it would be good to have food ready for the microwave. They straightened up their baby's room, folding the last of the freshly-washed onesies. They installed the car seat. They packed their hospital bags. They took a nap. And then they waited.

And nothing happened. At all.

Four days of nothing happening later, I was eating breakfast with them in their kitchen. I sat across from my client, chatting with her over a platter of bagels and a variety of cream cheeses. She was so very clearly not in labor. She'd even had a regularly scheduled prenatal appointment since her visit to L&D, and all was fine with the baby, who was perfectly happy tucked up safely inside her body.

My client asked me for an opinion on what I thought had happened, an explanation of the mucous and the bloody show. She was concerned, and maybe a bit discouraged, about why her labor had stopped, and I told her that I didn't think it had ever started. Ultimately, I guessed that she'd had some mild contractions, too mild to feel beyond a crampy sensation, yet enough to be traced on a fetal monitor, and probably enough to dislodge her mucous plug, which began her dilation. And most importantly, I told her that she made such a good decision to come home that day instead of admitting herself to L&D. Because had she chosen to do differently, perhaps we would have still been enjoying a lovely breakfast together at that moment, and she would have been holding a beautiful, healthy baby -- as she gingerly recovered from her c-section.