Wednesday, April 24, 2013

Another Entry from the Diary of a Doula

April, 2013
Last Tuesday I went with Makda (not her real name*) to her clinic appointment. The midwives had referred her to an obstetrician because they were concerned that she still had 2 weeks to go until her guess date (originally called the due date) and her baby already felt rather big. The other concern they had was that her last baby had gotten stuck during delivery with a complication called shoulder dystocia. It was scary enough that the last midwife made sure to attach an alert to Makda’s chart. So, here she was, due with another big baby and a bunch of very nervous midwives.           

The doctor did an ultrasound and guessed that this little guy, a boy was about 8 ½ pounds, which was what the last baby weighed, though she was only at 38 weeks now. She had two little girls at home, a 5 yr. old named Qwara, and a 3 year old named Retta. They had gotten used to me by now, though remained a bit skeptical -- especially since I couldn’t understand a word of their language, Amharic, though they tried to talk to me. They settled on high fives as a greeting and went back to the toy box in the waiting room while she and I went into the exam room.
            I was impressed that this doctor didn’t rush into the early induction option, especially since the weekend was fast approaching. (Most C-sections in the U.S. happen before 10 p.m. and not on weekends.) He explained that since this was her 3rd baby that she should be able to push out another big baby which she did after all last time. However, he hoped she would go into labor on her own in the next week. He hesitated and said that he would think about inducing labor after that if things didn’t start by then. He mentioned that he would be gone over the coming weekend but that they had a great group and he felt confident that she would be well cared for in his absence. We thanked him and left.
            I was also going to be out of town the next weekend (which is very rare for me) so I told her about my backup doulas, reassuring her that she wouldn’t be laboring alone. Her husband, Semere would be staying home with the other children when she delivered, which didn’t seem unusual to them. Men are not usually in attendance at births in traditional African cultures. It is one reason why our doula group in Minneapolis has become so popular with the immigrant women. They have aunts, sisters, sometimes their mother, and girlfriends to go with them when they have their babies, but the idea of a doula who can help them negotiate the often mind boggling American medical system, to them is a godsend which they are truly thankful for. (Hamduli’Allah! – thanks be to Allah!) In turn, I tell them that I am deeply honored to be invited to be a part of their most intimate moments and feel so welcomed at their births.
            It is always hard when we have set our sights on our birth going a certain way and all of a sudden, either before the birth like this one, or during labor everything changes gears. Makda and I had talked about what her wishes were, what she liked or didn’t like about her last 2 births and together had written up a birth plan. She and I had spent some of our prenatal visits watching YouTube births, especially water births, home births and natural births. I wanted her to understand that she has many options to explore and unless she knows about them, she really doesn’t have those options. She was especially intrigued by water birth, so we talked about that and included that in her plan too, but now this wrench in the works.
            She was discouraged. I could tell this was worrying her so I suggested that before she left that day we get the interpreter back and talk about it a bit. I come from what we call the ‘midwifery model of care’ where we trust that our bodies know how to birth and that they also know how big to grow this particular baby. The other model of care is the ‘medical model’ that has crept into our collective consciousness and the American way of life for over a hundred years now and in the process undermined much of our instinctual knowledge.
            So we have to find a way as doulas to navigate between the two, letting women know they are both out there, encouraging them to find that power that we believe is in each of us, but also stepping back when our sister is on this journey of self-discovery and may not be ready to be as daring as we would be (or wish her to be) at the place we find ourselves at this very moment.  I have to respect her choices and hesitations and not show even the least disappointment if she doesn’t choose what I would have chosen for this birth. A doula has to be there to unconditionally support whatever a couple feels is best for them. That isn’t always easy for some of us who are rather radical when it comes to crusading the cause of birthing women.
            And while we crusade for all woman-kind to become empowered, why do women who end up with a C-section or have chosen to use medications at birth feel that they have somehow failed? Do they think they failed us? Or themselves? Or their baby? Why do they think that we as women or as doulas and midwives will judge them? Have we set some imaginary standard so very high? Or have we made birth into a contest, a marathon or triathlon for that matter? How can we support each mother better and be able to say, “I am so very proud of you!” and mean it just as much at a Cesarean birth as at a natural un-medicated birth? I believe that it is up to us to change this self-worth, self-image contradiction we are seeing. I also believe that the para-medical community is partially to blame if women even perceive that they have somehow failed. We have to explore this further and be able to affirm each other better if we cannot answer a woman who has had a C-section with more than, ‘well, better luck next time.’

If we are to heal the planet, we must begin by healing birthing.
~ Agnes Sallet Von Tannenberg

            I talked with Makda and told her that there were also a few other things that might be able to help avoid having to be induced, if this baby was indeed ready. I suggested walking -- a lot, and that sex can actually trigger labor. Then I told her about Jeannie (who I wrote about earlier in March at this blog) who had been told that she needed a C-section the next day. I had told Jeannie back then that she could also talk to her baby and connect and perhaps find a way through the problem together. It had worked and she had a vaginal birth without complications just in time. I wished Makda a good night and hugged her goodbye.
            At 6 a.m. sharp two days later Makda called. She was feeling sick and not sure what to do. She had the chills, her stomach was upset, she couldn’t eat and had cramps but not contractions. She complained that her back hurt, too. I am not going to even try to figure out what is going on. As a doula it is my job at this point to direct her back to her midwife or doctor and let them decide what to do. It sounded like either early labor or a urinary tract infection, but I told her to call the clinic and let me know what they think she should do. She called me back and told me that they wanted to see her at the hospital, but she didn’t want to bring in the kids too, so she wanted to know if I would meet here there so Semere could stay home and watch their girls. She asked me to call the taxi which I did and soon met her at the hospital. Of course they had her on a monitor to track the baby’s heart beat and another monitor to pick up any contractions. There were both. She didn’t feel the contractions at all, and her water hadn’t broken. They ruled out anything else that might be causing her discomfort and decided to watch for an hour and see if anything changed. She was only 1 centimeter dilated.
            So I visited with her and figured we’d be sent home in the end. An hour later she was actually dilating and the contractions were picking up. We weren’t going anywhere – yet. I ordered some lunch for her and snacked on what I had brought, though I didn’t have my big doula carpet bag. I just didn’t think we’d be staying. I was wrong.
            Hour by hour she continued to open up though it was slow, but definitely progress. At one point the contractions picked up a bit and she started to feel them, but then they stopped all together. We walked for a while, glad to be able to move around finally. Her doctor came by later in the afternoon mostly just to encourage her. This was her third baby, but he was not in a big hurry. I kept her drinking plenty of juices which I think got rid of the chills or whatever fever was threatening to show up. Dehydration alone can cause symptoms like Makda was having. By evening things had pretty much stopped. The nurse called the doctor who suggested she just sleep and talk again in the morning and see where we were at then. I was glad they didn’t want to hurry things along with interventions. I was very impressed with this doctor’s level of restraint!
            I went home at this point but assured Makda that I would come right back if she needed me. I made sure she had my number handy and tucked her in. She had a good night, and so did I. The next morning the doctor suggested a very low dose of Pitocin to get the occasional contractions a little closer together. They were still there, but not at all effective. That did work quite well. Finally we entered that point-of-no-return called “Active Labor”. With my own five births, I remember this is as THE moment when you ask yourself each and every time, “what could I ever possibly have been thinking to want to be back at this point again in a million years?!” It is the moment when you think, and some say it out loud, “Let’s all just go home now and come back and do this tomorrow instead.”
            One of the resident doctors came to introduce himself to us and asked permission to observe this birth. Makda didn’t understand what this was all about, so I explained to her that he would like to stand in the corner and just watch and learn from this birth, that he was a student doctor and that this how they learn – and how we can contribute (hopefully) to their education including natural birth. That is how I learned, by watching midwives and doctors when I was in school. I explained that she had every right to say no, that there were enough people already involved, but she said it was perfectly OK and even put her hand out to welcome him. He read the chart and asked the senior doctor if, in light of the last shoulder dystocia, he was considering using the Gaskin Maneuver? I was floored! This was the first time ever that I have encountered a doctor who not only knew about Ina May Gaskin and the successful management of shoulder dystocia that was named after her, but was actually hoping to see it in action! The OB who was overseeing Makda’s labor at this point said, yes, it might help and he was familiar with it, but then added that a small vacuum might also help. I assumed he was more familiar with the latter intervention by the way he was explaining it. I couldn’t resist putting in my own two cents at this point and said, just as an aside, “Ina May Gaskin was at my twins’ birth on the Farm in 1982.” (See “Twin Birth on the Farm”© story on pg. 130 from Spiritual Midwifery 2nd ed. by Ina May Gaskin at this blog. Also see “Twin Vertex Birth”, a DVD from the Farm Video at http://www.inamay.com/natural-delivery-vertex-twins-dvd)
            The resident practically hopped up and down and said, “ REALLY? I just saw that video! That was YOU?” Well, wonders never cease! I said, yes, that was us. Later that night he came by with another young intern to meet me. I was able to give them my card with the blog address and upcoming book information. When did medical school ever look like this? I still find it mind boggling!
            So we walked, and labored, and breathed, and thought about giving up, and walked some more and took a long bath, the only sound water slowly trickling over her belly in a dark quiet bathroom and then our breathing together in unison, trying to slow down, and then blowing that rush away forever. Finally fully dilated we tried different positions for pushing. Hands and knees worked well, and the doctor was in agreement with staying there, especially if it would help with big shoulders, but Makda wasn’t sure this was working. The nurse checked and the baby hadn’t come any further down even with some really good pushes. Then the doctor checked and became concerned that he couldn’t feel the lines in the baby’s head. He wondered if he had turned somehow and could even be breech, so they rolled in an ultrasound machine to check. No, the head was still down, but looked posterior. That would explain the back labor, but not that he wasn’t budging. The doctor was fine with her pushing as she had the urge, but it didn’t look like she was getting him to move. At this point he ruptured the bag of water, hoping that would help with some progress, but what happened next was a surprise. Until then the baby had sounded great with nice variable heart tones. But the water was full of meconium. Baby wasn’t happy.
            The heart tones continued to look good, but all of the pushing wasn’t doing much good. Finally the doctor suggested trying a small vacuum that might help the baby’s head to move which he was sure by now was acyclic, or turned to one side and aiming down the birth canal at an awkward angle, which Makda agreed to right away. We all just wanted to see this baby out at this point. So that was tried and after three attempts, the doctor gave up on that too. Baby didn’t move. We had tried different positions and just about every trick in the book by then. All of a sudden I looked over at the monitor at the same moment that one of the nurses announced as calmly as possible, “fetal heart tone 50… 60… 50…” which meant that our baby was in trouble. 
        Back to hands and knees and monitors. I was the closest one to the oxygen port in the wall and unraveled the tubing, plugged it in and turned it up to 10 liters at the nurse’s direction as I passed the mask to her who had Makda breathe the oxygen and help out her baby. We tried having her on her side, then the other side, then upright. Nothing helped for long. After every contraction the baby’s heart rate fell dangerously low. The doctor wondered out loud if the cord was being pressed somewhere next to the baby’s head both preventing further descent and causing the low heart rates. He explained all of this to Makda and asked if she would be OK with an emergency C-section because the baby wasn’t doing well and we didn’t want to wait further. She agreed. She had been begging for a C-section around 8 centimeters but I had explained then that they would not even consider that for a healthy baby and mom. Little did we know that he would be in trouble so soon.
            At the moment she consented, the staff went into high gear. She was asked to sign a consent form. Compression bags were put on her legs and a sterile cap covered her hair. The IVs were all detached at the pole and monitors were shut off. A catheter was put in and a fetal scalp monitor to listen to the baby directly. Every minute counted. He still sounded OK which I was glad I could tell her, and I helped Makda pant through the contractions and take deep breaths as they passed. I tried to sound calm and quiet, hoping to diffuse the sense of panic around us. As she was being wheeled out of the room the interpreter and I were each tossed a set of scrubs, hats, booties and masks which we caught mid-air. We ran into the bathroom in the room and wiggled out of our clothes and into the scrubs as fast as possible without even closing the door and then ran down the hall to catch up to Makda. 
            While she was prepped for surgery I was able to hold her forehead and tell her what was happening. The IVs were all reattached, the epidural line was being transferred to the O.R. (operating room) equipment in the room, her belly was being scrubbed and then covered with a sterile sheet that would stick and stay in place during the surgery. Within 10 minutes or less the doctor was starting the first incision. I explained that she would feel pulling as they held back each layer of skin and muscle and then they’d be ready to lift out her baby. I told her he still sounded good – better even since we left the room. Within minutes I told her to expect some tugging and pressure…then I told her I could see lots of curly hair and before I could say more he let out a huge cry as they lifted him up. He looked pink and didn’t even need to be suctioned. Because of the earlier meconium the resuscitation team was on hand but he did better than anyone expected. He was in the warmer now and I lifted up the sheet to Makda’s left so she could see him as they cleaned him up and checked his breathing. He was doing great. I whispered in her ear that he was beautiful, and that we were all so very, very proud of her. As soon as it looked like the nurses were starting to wrap him up I asked if she could hold him now. They brought him over and I held him next to her so she could see and kiss him while they freed up her hands so she could hold him. He was blinking and trying to see her, too.
            Finally she was brought back to her room – this little hospital didn’t have a recovery room, so we settled back in where we had started. I was glad to see that for the trip back to the room they didn’t put the baby into a crib to wheel him down or send him to the nursery, but plopped him right next to his mom and covered them both with a heated blanket. The interpreter called Semere and explained that his son was finally here and he should come when he could find someone to watch the little girls. Makda instructed the interpreter not to tell him that she had a C-section because she was afraid that he would race to the hospital and get in an accident. She asked me to explain to him what happened and why when he arrived.
            About an hour later he came with the 2 little girls.They were dressed alike, and their daddy had even fixed their hair. One was holding a huge bunch of flowers and the other one had two balloons on strings for their new baby. An aunt was also along to watch the girls so Semere would be free to visit with his wife. Baby was left in the room when we explained that she wished to room-in and that her husband would be caring for the baby during the night. I explained to him briefly that the doctor was concerned about the baby and after trying several interventions, decided to do the C-section. I gave him a very brief outline and told him we would talk more when I came back the next day. I did say that I was very glad for the doctor we got and that the whole staff had been great, actually very caring and competent. I told him we had been very lucky. I told him, too, that he had a very brave wife and he should be very proud of her. I hugged them both goodbye and went home.
            When I came the next day Makda was up and walking around the room taking care of her baby. He was nursing well and she looked exceptionally well and happy. She had a few questions as she was trying to process the rushed chain of events before his birth. We talked about it all again, and also I told her that we were all very grateful for how supported she was and the great team she had.
            The midwife part of me still tries to analyze alternative possible scenarios, and what we could have done differently. The doula part of me knows I was there every minute to try to bring a calm and balance to her birth that she would remember always. I wanted her to feel that she had done a good job in spite of the problems and that she was still a strong, beautiful woman who was on an incredible journey of motherhood.
            We visited over lunch in her room, just so very grateful that little Azmera was here. She marveled that he was so peaceful and nursed so well. I reminded her what a good mama she was and that the older we get, the more laid back we often are, which babies can pick up on, too.           

"I've learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel." ~ Maya Angelou

*all names, ages and identifying characteristics have been changed.
 STAY TUNED: this and other stories will be appearing in the book, Call The Doula!: a diary© pending by Stephanie Sorensen

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