--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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What's in the Bag?

As a doula, I know the value of a held hand, whispered encouragement, and a guided breath. There is research out there stating that simply having a doula in the room -- even if she sits there and only observes -- increases birth outcomes. But still, what's in the bag?

In my doula bag, I've got heating pads -- the kind that are activated by air. I would like to carry a silk, rice-filled pouch that can be heated in the microwave and molded to a woman's body, but most hospitals don't allow them anymore. But the heat can feel wonderful against the back or belly during contractions. Conversely, I also carry cold packs, the kind that you squeeze until something inside pops, then shake, and the square becomes ice-cold. I don't use these too often, but when I do, it's often at the site of the IV or hep-lock (the port to attach an IV quickly). Some laboring moms like the ice on their foreheads or necks, when labor has them heating up, but I find that cold, wet towels are better for cooling them off. These are single-use plastic and chemical packs, so not very green; but in a hospital room, use of heat and cold is limited if available at all.

I carry essential oils. If the mom wants a massage, I'll mix the essential oils into grapeseed oil (essential oils can't be used directly on the skin). Clary sage oil is reported to regulate the uterus and organize contractions, and lavender oil encourages relaxation. Lemon verbena oil can also cut right through a woman's nausea. I don't know what the science is behind aromatherapy, whether it achieves what aromatherapists claim, but they sure do smell good, and sometimes the smells of an antiseptic hospital, or the raw smells of birth, can make laboring women uncomfortable (remember that laboring women can have acute reactions to scents, however!). Any of these oils can go on the aforementioned wet towel, or on cotton balls, which are also in my doula bag.

I carry a deflated birthing ball and pump. If there's a ball already in the labor room, great! --but mine is always there just in case.

I bring a gardener's kneeling pad, so if mom is laboring on her knees, she's not on the hard linoleum.

I have a 6 foot long beautiful shawl, which can be draped over mom if she gets chills. The texture and colors are rich and luxurious, very pleasing to the senses. One of these days, I'd like to get a rebozo training, too.

I have two combs, one that mom can squeeze in each fist during contractions. When held perfectly, the teeth on the comb stimulate acupressure meridians that encourage labor to progress. And mom can squeeze them as tightly as she likes, dispersing the sensations of contractions as much or as little as she pleases.

Two cosmetics bag -- one for me, with saline solution, a contact lens case, tooth brush, toothpaste, hairband, and breakfast bars for quick energy; one for mom with hard candies, new lip balm, and a hair band for her.

And a hand mirror. Some moms want to see their baby's heads emerging. It can be great encouragement for only a few more pushes when she feels like she's got nothing left, and it can provide a view of that once-in-a-lifetime moment as the baby crowns. Hospitals haven't figured out yet that hand-mirrors are easier. Instead, they lug these heavy mirrors on rolling stands. Such a bother, and many laboring women still don't want people to "fuss" over them.

What's in yours?
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