--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 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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September Snapshots

There are moments that will stick with me forever from this September:

-- Baby Ryan's parents: laughing and smiling as he entered the world so quietly, so gently.

-- What autonomy, what I value most in my work, looks like: Client F, who labored through the night and was admitted at 9cm, said to me: "An epidural was always a part of the plan. I'm not ready to deliver yet, and I need to sleep before I start pushing."

-- The power of love from a visitor: as the long night stretched into the day which also wore on, with virtually no change in the cervix whatsoever, Client A's best friend came into the room. The husband and best friend embraced the mother in an intimate circle and simply held her, overcoming the resignation in the room with love.

-- The muscular, sinewy strength of a laboring mother, whose low moans began ending in grunty pushes, reaffirming that birth is the most primal of all instincts.

Thank you to all my September families, for the privilege to participate.

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It's National Midwifery Week!

Please celebrate National Midwifery Week by honoring your midwife. What is ONE word that comes to mind when you think about your birth experience with your midwife?

I choose collaborative.

And to add, I will thank her again and again for how we worked together on my pregnancy and my daughter's birth, but also for how she shaped my work as a doula.

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Hospital Based Doulas, Johns Hopkins

Here is a quick and simple article about how hospital-based doulas can enrich a woman's birthing experience. Note that the experience is mother-centered; the doulas do not have an ideal birth in mind for the mom, but they are there to support the mother and her needs as she defines them.

Unfortunately, the only two Boston area birth center/hospital-based doula programs have been wildly cut in the recession, with budgets for only the absolute, highest-risk mothers.
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Radical Doula

My blog post regarding the death of Dr. George Tiller caught the eye of Miriam Perez, an editor at Feministing. Miriam is also a doula and women's health activist who chronicles her work at Radical Doula.

Miriam interviewed me via email regarding my work as a doula, and I'm flattered to be featured by her work. Thank you, Miriam!

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Who Needs a Doula?

Thanks, Kathy Peterson, for a concise and articulate explanation of one the doula's many roles -- advocacy.

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Keep on Movin', Mama!

Henci Goer has blogged for Lamaze's Science and Sensibility this week about a small study that suggests the high value of freedom and variation of mobility for laboring women.

Combine this with the ACOG's recently revised guidelines about external fetal monitoring (EFM). As a doula, as a woman in labor, I have seen how the fetal monitor seriously impedes a woman's range of motion. Movement, particularly bending over or forward, can either pick up the mother's slower heartrate or lose a heartrate altogether. The sheer frustration can make a woman surrender to the bed, despite her primal instinct to move with her labor -- if her care providers haven't already forced her to stay there for the sake of that printed read-out. But the ACOG now states that "although EFM is the most common obstetric procedure today, unfortunately it hasn't reduced perinatal mortality or the risk of cerebral palsy. In fact, the rate of cerebral palsy has essentially remained the same since World War II despite fetal monitoring and all of our advancements in treatments and interventions. " The low-tech and far less restrictive intermittent use of doppler radar or fetoscope, typically used in out-of-hospital birth, relays reliable information about fetal heart rate.

All the more reason for mamas to keep moving.

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Who's Birth Is It Anyway?

My customary closing, when I respond to an initial email from a woman looking for a birth doula, is "Enjoy the rest of your 40 or so weeks, and best wishes for a wonderful birth-day."

When we meet in person, I will start the conversation by asking "What are some of the ways you envision your birth?"

But who's birth is it, really? Isn't it the baby that is being born?

I admit I never gave much thought to this use of language until a friend was critical of someone else's homebirth. The woman blogged about her birth in heroic, Herculean terms, and my friend found it boastful. "It's just a notch in her belt," he argued. "And it shouldn't be about her. It should be about a healthy baby." His assumptions about the healthiness of homebirth aside, his feelings are only a reflection of the way birth is typically viewed: a medical event meant to be just barely endured. And if the birth is traumatic, the disappointment with the experience gets swept aside by saying "In the end, all that matters is a healthy baby."

Of course we all want a healthy baby. A healthy mother, too. But there are women who envision something different than a delivery that is done to them, under a cloud of fear and suffering. They want to experience the physiological process of birth: the wonder, the fear, the ecstacy, the pain, the awesome strength of her body's own power to thrust another human being into the world. Their babies will be born, and these mothers want to birth them.

To my clients, I wish them all a wonderful birth-day.


cross-posted on Massachusetts Friends of Midwives blog.

Birth and Death: Right Around the Corner from Each Other

In yesterday's NYT, an eloquent realization that midwives care for women and babies, and not just at the beginning of life.

Anyone who cares for a woman during childbirth -- or in this case, stillbirth -- our near-sacred calling is to create and hold space for the pain, the ecstacy, the joy, and the loss.

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Women Must Be Informed, Political Collaborators in Their Own Care

Dr. Tiller's clinic in Witchita, KS, one of the few in the country that provides late-term abortions, is closing. With his murder, in addition to wiping out the life of a husband and father, the anti-choice movement has taken away women's access to critical, necessary services. And while the current political make-up shows that the anti-choice movement cannot overturn Roe v. Wade, Dr. Tiller's death is a reminder that all it takes is a sniper to reduce our choices even further. And since OB-GYN's aren't racing to provide abortion services at the risk of their own lives, Dr. Tiller's practice may not ever be replaced.

When I'm not a doula, I work as an abortion counselor. Although most of the women I meet with are between 4 and 7 weeks pregnant, the clinic where I work provides abortion services up until the 23rd week of pregnancy, which is the legal limit of abortion care in the state of Massachusetts.

Your reaction may be visceral, no doubt. At 23 weeks, abortion can be extremely difficult to understand or justify, and it is not uncommon to shake your head and say "I have a real problem with that," even if you are pro-choice. It is tempting, if not comforting, to separate yourself from a woman who would make this choice by assuming that she must be a monster. And I'll be honest and say that once I sat down with a woman who seemingly had no feelings about having an abortion in her 23rd week of pregnancy. It chilled me, her apparent lack of feeling. But many more times than just once, I have sat down with couples who are heartbroken: a routine ultrasound in the 20th week discovers massive deformities; an amniocentesis details profound genetic abnormalities that at are incompatible with all but the briefest of life, and suffering is certain; a doppler at 22 weeks returns no heartbeat, reducing a wanted and cherished baby into a diagnosis of fetal demise. And sometimes, due to the time it takes to run tests, or to the human inconsistencies of those who administer those tests, or the varying reliability of technology, a pregnant woman in those situations can be beyond 23 weeks. And so what do we do in the state of Massachusetts? We tell her she can deliver her dead, deformed, or doomed baby in a labor and delivery unit of a hospital -- which is as monstrous as it sounds -- or we recommend she travel immediately to one of the few clinics in the United States that can terminate her pregnancy. And with the death of Dr. Tiller and the closing of his clinic, there is now one less place where a woman in this delicate and devastating situation can go for care that is humane and treats her with dignity.

And on the other end of pregnancy, women are also losing choices in childbirth. In my line of work, I hear many birth stories from women, and the majority of them have the same eerie arc: first, induction; second, confinement to a bed; third, bone-crushing pain; finally, forced pushing while lying on their backs. Statistically, more than 30% of those stories end in c-section, and these are in pregnancies that had been normal, low-risk, and healthy. It's also the basic formula for reality birth shows on cable TV, where birth is boiled down to a medical event that skirts death practically every time.

VBACs are becoming harder to access, despite evidence that indicates that VBAC is lower risk than repeat C-section. Providers, among both OB's and L&D nurses, have attended fewer and fewer low-risk, healthy childbirths that are purposefully unmedicated and without interventions. What results over time is that if a laboring woman wants a natural birth, she could go to a hospital and have no medical professionals with the experience or willingness to support her desires. Birth centers are losing funding, and homebirth is either criminalized or unregulated in half of the US. In the other half of the country, the standards of care that do govern it are so limiting that its practice is nearly impossible but for a few renegade midwives who are essentially providing care without the benefit of professional support in case of a true obstetric emergency. Healthy women who could experience the normal physiological process of birth are beholden to the artificial constructs of time, liability, and television drama. The art of childbirth, and the choices that encourage birth as a safe, non-medical event, are being lost.

Unless we have a vision that is greater than the arguments of pro-life vs. pro-choice, homebirth vs. hospital, natural birth vs. epidural, we will lose what is truly at stake at the heart of these issues: choices. The quality of women's health care is dependent upon choices and access to qualified care providers, and women must expect no less than to be informed, political collaborators in their own care.

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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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Do You Doula?

What's a doula?
Another great video sprung from the BirthMatters contest.

The Divisiveness of The Atlantic Monthly's "Case Against Breastfeeding"

These are the kinds of debates I hate, largely because I refuse to take sides. Yes, I'm a doula. Yes, I have a bias for normal birth, and yes, that leads neatly into a bias for breasfeeding. But Hannah Rosin has some interesting points.

Having not done a literature review myself about the nutritional comparisons between breastmilk and formula, I am surprised, and frankly still skeptical, that medical meta-analysis is not overwhelmingly in favor of breastfeeding. And while I do know breastfed people and formula-fed people who are of equal health and intelligence, a part of me never questioned breastfeeding. Even if breastmilk were an utterly neutral liquid, it is what my body makes solely for my baby, who was also made by my body. In the natural order of things, of course I chose breast over formula.

But I like that Rosin is honest about the fact that breastfeeding is no picnic. Continuing to breastfeed your baby does require significant accomodations with work (many women will nurse for their maternity leave, and the return to work marks the end of nursing), patience from other children (how many times has one child needed something as soon as I settle in to nurse another?), the division of labor in the home, and yes --sleep. Episodically, I have been nursing for the last 7 years, for about a year and a half at a time. I cherish it, though sometimes I've been downright resentful that my husband can't nurse, too. And though it's been all natural and made-by-mom, one of my children has anaphylactic food allergies. Who would have known that until I eliminated her allergens from my own diet, my breastmilk was actually toxic?

And though I cherish nursing, not all mothers do. Though many of them want to, it is painful, and they cannot continue, regardless of the support of numerous lactation consultants. (And I am a little taken aback by the way Rosin diminishes lactation consultants. Perhaps it is because she doesn't understand how, LC's -- most of them nurses -- have assisted enough women with breastfeeding to meet the thousands of contact hours needed to be certified. ) For others, due to a variety of hormonal reasons, milk production is low, which can then lead to the relentless path of nursing-pumping-supplementing with the dreaded formula leaving no time at all to actually enjoy a newborn baby, but plenty of time to be anxious that the baby is dehydrated and starving. And for some mothers, mothers who are equally devoted to their children and absolutely selfless in ways of mothering that I could never be, breastfeeding requires mental and emotional space that is just too intimate, maybe even stifling. I have worked with too many women for whom breastfeeding was at the cost of their mental health, and I find that unacceptable. No amount of colostrum or antibody is worth that.

But what I find most upsetting about the article is not the article itself, but the comments that are being left in the blogosphere, comments that question Rosin's personal decisions, her parenting skills, and her devotion as a mother. The comments only prove that there are indeed breastfeeding fascists out there, as the author calls them. I don't like this debate because there is no answer, only judgment, and its a tension that I see in the birth world too often. It is the breast vs. bottle chapter, like the natural vs. medical childbirth chapter preceding it, in the book of how women deride each other's choices. Rosin's article shows that statistics can be used to prove a point as well as its counterpoint, but nothing is more salient than a community of mothers who feel supported and respected by their peers, employers, family members, and care-providers, so much so that they feel confident in the informed choices they have made and can resist the need to judge the choices of others.

Is it REALLY about the epidural?

When I tell people I'm a doula, one of the responses I get is a shake of the head, coupled with "Nah, I go for the drugs!" Or "Why should I experience pain if I don't need to?"

I loved this entry from the blog "Empowering Birth." What woman wouldn't want to walk away from her non-medicated birth experience with the sense that now she can accomplish anything in the world? What woman wouldn't want that feeling from ANYTHING? What mother wouldn't want that feeling for her daughter? The craving for this experience is what motivated me to have my third child with midwives at a birth center.

But as I delve deeper into the world of birth -- as a mother who has had three wildly different birth experiences, as a doula who has attended many births, and as an aspiring midwife -- I dare to say that it is NOT about whether a laboring mom gets an epidural. Pain is subjective. What one woman can tolerate for 24 hours, another may not be able to tolerate for 24 minutes. Is one woman stronger than the other? Is one woman's birth better than the other? A woman's body has the ability to grow and birth a child. There is, in fact, nothing more natural than that act of creation and birth, epidural or drug free, at home or in a hospital. Witnessing a birth is a phenomenal, powerful experience no matter how the birth happened and what circumstances led to its unfolding.

Because I am a trained mental health clinician, I know that people have all kinds of experiences and make very different decisions than someone else would in the exact same circumstance. None of it is up for judgment, and as a birth professional with a background in mental health, I'm very cautious about even the mildest suggestion that a woman who chooses an epidural is less-than or that the babies had a less-than birth. In fact, I'm very cautious about the suggestion that a woman who chooses an elective, first-time cesarean is less-than.

My birth passion is more focused on freedom of choices. Is a pregnant or laboring woman making a decision about her baby's birth out of fear? Does she have the supportive people she needs to form a circle around her? Is she making an informed decision about her body, which decades of trends and popular culture have taught her to dislike and distrust, if not abuse? Natural childbirth is not only about the epidural. It is about our culture; our love and reliance of technology over our instincts. It is about our need to control a normal, healthy process that should be allowed to take its own path and power and time, and intervening only when it is medically necessary. It is about a culture that focuses on liability and lost income or productivity more than the intangibles, like faith and trust.

Actually, I think that the last thing natural childbirth is about is that epidural. It is about all that is normal about birth. That we don't know when it will begin, nor do we know how long it will take. It can surprise us, and yet if we can remain watchful while still being patient and respectful of the process, it will reveal itself as all that it is meant to be.

The Nature of Nature

As a doula, I have seen a million natural birth videos, showing women with glowing, ecstatic faces. Their births are peaceful and gentle, transcendent. Or the stories are of Homeric journeys, women whose bellies are their body armor, and in the mist of a new morning after a long, dark night, rise triumphantly. Women who cry out, "I never knew I had such strength!"

I engage in a fair amount of childbirth education with clients. While I worry about the woman whose idea of birth comes from reality TV or prime time dramas made for entertainment purposes, I worry equally about the woman who has only watched videos that promise her either bliss or empowerment -- in exchange, all she has to do is birth naturally. I do emphatically believe in the revolutionary idea that childbirth is not something we should be taught to fear; but as birth professionals it is critical that while we educate women to trust their bodies and trust the process of birth, we should also remember that the uninterrupted process of birth can be full of surprises. Nature - responsible for crystal streams, painted mountains, and skies spotted with sparkling jewels - is also responsible for hurricanes and gale-force winds.

As a pregnant woman anticipating my 3rd labor, I made all the right choices for a natural birth: I got prenatal care from midwives, chose a birth center instead of a hospital, and shook my head when well-meaning friends suggested that it was time for an induction as I got more uncomfortable. I was determined it was going to happen naturally, and it did. But my labor was naturally precipitous, and if I were to compare it to something in nature, it would be a riptide.

There are women whose birth stories have them, somehow, scanning the ocean in search of the crest of the wave, and once found, they ride it, shifting their weight here and there so that they don't fall if they begin to lose their balance. The sea water is spraying them in the face, and the mix of salt and perspiration on their skin is invigorating, affirming. And then there are other women in the riptide who are like me. I didn't fight it. I didn't navigate it. I didn't negotiate with it in any way. For weeks I have struggled with the mental picture of me being knocked down by a single wave; but I am starting to see that a woman's strength in birth is also in the letting go and allowing herself to tumble fearlessly with the current, never losing sight of the belief that, when the energy of the tide is through, she will find herself upright again on the shore.

High-Tech vs. High-Touch Maternity Care

Please click on the title above to read a simple, straightforward summary about the benefits to keeping interventions low in childbirth, from Consumer Reports -- a fairly benign publication that reaches out to a wide segment of people, not just alternative health or alternative birth populations!

Precipitous Labor

"pre cip' i tous: adj. Like a precipice; extremely steep; abrupt or ill-considered. "


That is the definition found in the 2nd edition of the American Heritage Dictionary. Medically, a precipitous labor is a labor that results in a birth in 3 hours or less. We all have seen on the news the story of a woman whose baby was born in a car en route to the hospital, or whose kindergartener knew enough of his numbers to call 9-1-1. Like many doulas, I have a precipitous labor clause in my contract to ensure I get paid, even if I miss the birth. I suppose many of us, if we attend enough births, will experience (or miss experiencing, even) a preciptious labor or two -- but for the most part we wouldn't bet on it, and wouldn't want to.

Just over 2 weeks ago, I gave birth in an hour and 17 minutes. I have a friend who said that she had a quick labor, too, and then she described how she pushed for just 20 minutes. She had obvious pride in her birth story, so I didn't tell her that her labor wasn't anything even close to mine. My labor was rapid. Like, really rapid. Like at 12:30PM, I was eating lunch and chatting with my husband, and then by 1:47PM there was a baby in the room. The dictionary definition of "precipitous" is far more accurate than the medical definition; my labor was like being thrown off a very steep cliff with no chute, and I free fell all the way until my daughter exploded out of my body.

A goal of natural childbirth requires values clarification, a real sense of why you want to birth naturally: do you believe in normal birth, and that in the absence of true medical necessity, there is no need to intervene with its process? Do you believe in your own primal strength? Or do you want your strength challenged? I've even had a client flat out say she was so terrified of needles that in fact an epidural was far more frightening than unmedicated childbirth. Natural labor also requires planning and practice; in other words, lots and lots of fore thought. And all my plans were tossed out the window - there was no time to collect myself, no time to process, and I had to use only what remained: my instinct - to breathe and keep the air moving through my body; my husband - whom I held on to for dear life as he supported my weight and helped me rock and sway through this deft force of nature, and my midwife - who, despite the collective surprise of everyone in the birth room at such a swift and decisive labor, entirely believed as I did that nothing was ever wrong, and there was nothing to be afraid of.

I am left with the sense that I didn't so much give birth as I did give way to birth, and I am feeling far more humbled by nature than I am empowered or heroic. My "precipitous" labor certainly was "abrupt", though not "ill-considered," and yet, in the end, just as it was meant to be.

Fence-Sitting

I told a good friend that, unexpectedly, I was pregnant. She said to me, "But you work as a doula. You are surrounded by pregnant women and newborn babies all the time. It's not that surprising that you're pregnant!" Another good friend's response was "You also work as a counselor in an abortion clinic. You know how these things happen -- how could you be surprised that you're pregnant?"

So that's what it's like sitting on a fence. My husband and I agreed not to make any decisions right then and there, and gave ourselves permission to ride a rollercoaster of emotions, come to any number of decisions, and then change them again until we finally settled on something that felt right.

A fellow doula offered her congratulations, saying "What a gift it is to go through a 3rd pregnancy, knowing all that you know about childbirth." And true, if I chose to continue the pregnancy, I had a plan for my prenatal care and very definite goals for my labor and birth. But the truth is symmetrical; I also knew every step of the abortion procedure. I knew exactly where to go, nothing to eat or drink after midnight until after my procedure was done, and that I needed to ask for an anti-nausea agent in my IV sedation. I knew that the doctor would write words on my medical report to indicate that the procedure was complete, and the likely words would be "fetal parts", "villi", "sac" or "POC," which stands for Products of Conception.

This is actually my 4th pregnancy, as I had a miscarriage between my two daughters. The gravity of the loss I felt at that time took me by surprise. I grieved as if someone had died, and I was barely 7 weeks at the time. Ironically, four years later, here I was waiting to be 7 weeks, so that if I were to terminate, there would be less likelihood of complication. But unlike my miscarriage, this time I had a choice, and I had never felt such ambivalence. I didn't want to bring another child into the lives of my daughters just because I was afraid to have an abortion. How was it that I could offer support and smiles and reassurance to dozens of women who make that choice every week?

I do occasionally sit with ambivalent women at the clinic. Women who take more than 20 minutes to fill out a single registration form, women whom we see through our security cameras sitting in the car long after they've shut off the engine. When I talk with them in counseling, I tell them that it is one thing to consider abortion, to look it up online, to make the appointment. But it is a different thing altogether to show up, to sit in the waiting room with a dozen other women who are there for the very same reason, and then actually go through with it. Some of them, especially if they are very early in the pregnancy, I counsel to go home, (I always wish I could open the front doors and shout out to the protesters, "Letting one go!") because a 1st trimester procedure can be done up to 14 weeks into the pregnancy. Because she has the time, I suggest she talk to her friends, garner the support she needs, and then if she returns, I assure her it will be easier. I imagined myself as the patient with any of my fellow counselors sitting in the room with me, explaining to me all that I already knew. And in my mind I could see them sending me home, and with a kind smile, saying "Maria, you are not ready to make this decision today."

Nine weeks into my pregnancy, I had my first prenatal appointment with a midwife. I chose not to share with her that my pregnancy was due to an act of carelessness. I also didn't disclose that abortion was still an option (which makes me feel silly in hindsight, as I rarely sit down with a woman at the abortion clinic who is voluntarily terminating her pregnancy despite having begun prenatal care). Nine weeks was also when I began spotting. I had been spotting for a few days by the time I saw her.

She sent me for an ultrasound, and I remembered my previous pregnancy loss. I wondered if maybe God was punishing me. For getting pregnant so thoughtlessly and then responding with indecision, my penance would be miscarriage, and then my husband and I would never, ever, ever take a chance again. I would continue my thriving doula career, coaching women through childbirth and breastfeeding, knowing that I would never again be a laboring or nursing mother, because we would never again let an accident like that happen. I lay on the exam table in radiology, the technician rolled the transducer over my belly, and there it was: a tadpole with a little flashing light, a heartbeat. I cried through the rest of the exam, which I hadn't done years before when the ultrasound had shown no heartbeat. I felt relief that I wouldn't have to experience that again, the bleeding, the clots, the pain that wrapped around my waist from back to front - the labor of a miscarriage. And though it would be a while yet before I would feel a rush of attachment for the image on the screen, I knew that my third journey into motherhood had already begun.