Sunday, April 7, 2013

Belly Casts, Babies and Negasi’s Birth

“It's not just the making of babies, but the making of mothers that midwives see as the miracle of birth.” ~ Barbara Katz Rothman, Sociologist, Author

Last week Miruts** came in for her last prenatal meeting before her due date. We had signed up for the Belly Cast Room for a slot early in the afternoon. We offer this as part of our doula services for our expectant moms.

            Everyday Miracles in Minneapolis is my home base. (see: www.everyday-miracles.org) About 25 doulas from several nationalities meet moms and their families here for prenatal classes, yoga, car seat clinics, and general support especially for low income mothers. We have doulas who are Hispanic, Somali, Hmong and a melting pot of Americans. Sometimes our clients are single mothers, teenage moms, or recent immigrants to the U.S. We see women from the whole metro area in the Twin Cities and attend their birth at any one of the hospitals in the area. As a doula, we also follow up with a postpartum visit to ensure that they are doing well and that mom and baby are getting the hang of breastfeeding.
            I am not sure when this art form called Belly Casting came into being. It is one way to help an otherwise overwhelmed young woman bond with her baby before birth. Some call it taking pride in their changing body or bonding with their Bump. However you put it, there is an awesome transformation taking place here: a little human being is growing, soon to make his or her momentous appearance on Earth. Part of the job of a doula while she tries to emotionally support a mother-to-be is to help her fall in love with her baby. There are numerous distractions threatening to obliterate this fragile connection. A young woman often has to face questions of employment, schooling, even where she will live with her baby. Relationships often become brittle as the reality of a baby sets in. The responsibility for a new little person can affect all the different parts of a woman’s life.
            Sometimes our job is to try to find ways to gently steer attention back to this connection or bond with her baby. We try to find ways to celebrate the life that is growing within each new mother. One way is to create a belly cast toward the end of her pregnancy. It is also a chance for the doula and the mom to share some special time together before labor and delivery. We will be working together once labor starts and will need to know each other quite well to work as a team.
            When we create a belly cast we first put a tarp down on the floor to catch any drips. Then the mom takes off her blouse and bra and using Vaseline or lotion coats her belly, chest, under her arms and down her sides. I tuck Saran wrap along the top of her skirt or pants to protect them from the plaster. We use plaster coated gauze sheeting that comes in strips that used to be used to cast broken limbs. You dip a sheet into warm water and layer that on until her whole belly and chest up to her collar bone is covered. I usually lay on 2 layers. Within 10 minutes it dries and pulls away from her skin. We gently lay it down on the tarp to finish drying while she washes off with fresh warm water and soap.
            Many women paint their belly cast. Some decorate it with henna patterns. Others bring it to their baby shower and have everyone write wishes or blessings on it. The possibilities are endless.
            Miruts was not due for over two more weeks, so I was surprised when Tamirat called me at 5:30 a.m. two days after I had done a belly cast for her. He was quite upset as he explained that his wife was bleeding and they had called 911. I asked if she was having any contractions and he said no, none. I asked if it was a little, like spotting or a bloody show and he said no, it was all the way to the bathroom and back again and on the bed. I stopped breathing. All I could think of was, why them?
            They had come to the U.S. less than a year before from Ethiopia, with a stop in Sweden until they could get U.S. visas, seeking a better future for their children. They were learning English and working hard to assimilate. They have a beautiful little girl named Selam, who is sixteen months old. I had really enjoyed getting to know this little family and looked forward to this baby with them these last few months.
            I raced to the hospital, praying the whole way. I don’t know if we can alter a divine plan, if such a thing exists, by prayer, but I was going to try anyway. All the causes of early bleeding were racing through my mind, placenta abruptio (also called an abruption) being uppermost. This is when the placenta begins to detach from the inner wall of the uterus before the birth of the baby. Sometimes just a portion of it comes off causing bleeding and the remaining part is still able to deliver blood and oxygen to the baby through the umbilical cord, but should it completely come away from the uterus, that oxygen is cut off and the baby cannot survive. It is one of the causes of a stillbirth. Another possibility could be placenta previa, where the placenta has attached to the uterine lining near or over the cervix itself, close to the opening of the uterus.  Occasionally we see a uterine rupture, where there is a tear in the uterus at a weak spot, though this is more common, although still rare, when there has been a previous C-section, and the strength of the contractions stress that area. That can also cause bleeding, even hemorrhage.
            At this point, all I knew was that I was scared, more scared than I have been in a very long time, and I could hear Tamirat’s fear too. When I arrived at the hospital Miruts’ midwife was watching the baby’s fetal heart tones on the monitor by the bed. They checked out OK, which was a huge relief.  The monitor also showed us that there were contractions coming at regular intervals, though Miruts wasn’t feeling them yet. When the midwife decided to check to see if she was dilating, this produced a fresh gush of blood – not a good sign. The midwife left to call the obstetrician on duty that morning. I tried to let Miruts know that the baby still looked good, and that they did the right thing coming in so soon. She was not panicking up until now, but when the midwife left to call the doctor, that alarmed her very much and she started crying.
            When the doctor came in he first reviewed the read-out from the monitors and agreed that the baby was still doing fine, though the heart beat was fairly unchanged throughout, what is called non-variable. He ordered an ultrasound hoping to get a look inside the uterus and maybe get a clue as to what was going on, but the baby appeared to be toward the front of the uterus, covering a posterior placenta, meaning it was attached to the back wall, or closest to the mother’s back which made it impossible to view; he also couldn’t tell how high or low it was either.
            Then the doctor suggested breaking the bag of water. His rationale was that this would inform him further if the baby was feeling stressed in which case he might consider a C-section or if baby was OK we could continue to wait a bit longer. When babies are not doing well or feeling stressed as might happen if less oxygen was being delivered to them, they often poop in the water before birth. Then the amniotic fluid turns green or dark, sometimes with dark particles. Artificially rupturing the bag of water at this point could also possibly help hasten labor along. The doctor explained that the baby needed to be born sooner rather than later today, and though he or she looked fine now, he was continuing to weight the options left to him. He could do an emergency C-section, but the risks of major surgery were a serious consideration, especially if the mom is bleeding already. The baby was still doing OK so ideally a vaginal birth was still an option and might pose less of a threat to the baby. This doctor was weighing the pros and cons minute by minute and you could visibly see his concern. He spoke about using Pitocin should the contractions not pick up or the baby’s status change. But first he went ahead and broke the water – a simple procedure that the mom doesn’t feel. An amnihook, a sterile plastic probe is used to snag the amniotic sac. A small hole will allow the fluid to seep out a little at a time if the baby’s head is not entirely engaged. Care must be taken not to try for too aggressive a tug which could tear a larger hole in the bag allowing for a more forceful gush of fluid which has the potential of bringing the umbilical cord down with it. Then the baby’s head could conceivably pinch off the flow of oxygen before birth.
            Usually we don’t like to see this or any other intervention used, and a couple could refuse it, but in this case and at this time it seemed warranted. When births unfold as this one was doing, parents often turn to me and ask if what they are doing is the right thing. Many have planned an un-medicated natural birth and had never even entertained a thought otherwise. When our births don’t go as we planned -- and remember, we don’t always have complete control over our births -- and we find ourselves on a totally different planet, when I am asked what I would do in this case I pull out my Welcome to Parenthood Talk. It goes like this:
            “Welcome to Parenthood! You must find out what is right for YOU, not me, not the doctor or midwife, not your mother or mother-in-law. You must go into your hearts and together find out what is best for you, for your family. You’ll make lots of mistakes along the way, but it’ll be like this for the next 18 years or so. This is only your first test. You can’t ask anyone else what to do. You have to decide this one for yourselves. And you will know. And we will support you.”
            Fortunately, the fluid was clear, indicating that at the moment at least she or he was not exhibiting any signs of stress. At this point Miruts’ husband, Tamirat asked to see me in the hall. He was beside himself with worry. Their first baby had been born in Sweden the year before, in a birthing room with a midwife, a natural birth lasting only 5 hours. This was so very different and he was losing it. First, he didn’t understand why he wasn’t being consulted on every decision that was being made, and he didn’t understand the reasons why a C-section was being mentioned at all. In his country, he told me, an elder or at least a husband would be consulted by the doctor, and the patient rarely advised on all the aspects of her condition, partly to spare her worry or concern and also since she may not be in the best position to decide these things.
            I explained that in the U.S. we have innumerable laws giving the patient complete rights over her own body and subsequently her own treatment and then only when she agrees is her husband or partner or family brought into the discussion. His English was adequate, but there was the whole cultural barrier that he was trying to bridge here. We were able to go over each point that the doctor was concerned about until Tamirat was satisfied that everyone really was trying to find the very best course to take for his wife and baby.
            Very soon then, the contractions picked up, which often happens after the water breaks and triggers a hormonal response in the brain. This was a good sign, and the baby continued to tolerate the stronger contractions very well. I couldn’t give Miruts juice or even water since they were still leaving the Cesarean option as a possibility, but I did succeed in getting her nurse to give us some ice chips, which was better than nothing at this point. Miruts was breathing well with the rushes and getting up to the bathroom. She was dilated to 5 cm. the next time the nurse came in and the bleeding seemed to have slowed down, all good news. The nurse left us alone at this point. She had other patients and of course could follow our monitors back at the nurses’ station should anything change. The next time she came in she surprised us when she announced that the cervix was now at 8 cm. It had only been about half an hour since the last check. She scurried out to let the doctor know. I took one look at Miruts and knew she was already thinking about pushing. I hit the nurses’ light on the bed rail as I put on a pair of gloves and sure enough, Miruts took a deep breath and gave it all she had with the next rush. I helped her slow down her breathing just a bit as the nurse ran in. She started to put on a glove as the little head crowned. I picked up the other glove she had dropped on the bed and held it open as she shoved her hand into it, barely in time to catch a very plump little baby. The doctor walked in just then. I saw that the nurse was trying to un-wrap the cord which was around the baby’s arm and then her chest, so I moved in and held the baby by the hips so she could unwind the cord. At the same moment the doctor came up behind me and gently told me to hold the baby’s hips higher which I did, basically turning the baby head down which would drain any fluids, extra blood included, before she or he took a breath. Then the doctor gave the nurse the umbilical clip and hemostat clamps and handed the scissors to Tamirat. All this had taken place in complete silence. At that moment, the baby let out a huge screech. When he heard his baby, Tamirat started sobbing, so relieved that his wife and baby were out of danger. He blinked back tears as he cut the cord. Then the nurse turned to him and asked, “Well, what is it? A boy or a girl?” Earlier I had clued in the nurse that they didn’t know the baby’s sex, and I thought it would be nice if we left it to Dad to announce.
            With the advent of sophisticated ultrasounds today, we rarely don’t know the baby’s sex, so when this happens, I let the father or partner have the honor of making this announcement. I did this last year with a couple from Kenya. The midwife had caught their baby and in one fluid movement plopped it onto the mom’s stomach. All that the father saw was the backside of their baby, but thought that was enough. He started dancing around the room yelling, “I have a boy! I have a boy!” He even called the relatives in Kenya with the announcement during the next 20 minutes or so. Finally the mother asked me to take the baby so she could sit up and get cleaned up and when I did, I noticed something different. I nudged her and whispered, “Look here,” and she laughed out loud. They had a girl! He had never seen a baby girl it turned out, and just assumed baby boys looked like that, from behind at least. He had to call Kenya back.
            The placenta followed right away with hardly any more bleeding. It was over. We all breathed a huge collective sigh of relief. Tamirat went from kissing his brave wife to thanking the doctor and nurses, to crying, and kissing his wife again. Of course the nurses offered to weigh the baby right away, but we had already discussed this and put it in our birth plan that they preferred to just bond and put off everything else for a couple of hours. I find that nurses are generally relieved when they hear this; it takes the pressure off of them to hurry through the list of things they are required to do before the end of their shift. They simply chart, ‘mom refused’ and they are let off the hook.
            They needed time to take everything in, first of all. It had been intense. It was only 3 hours from the time they had come in by ambulance. This labor was even shorter that their first baby’s had been. It is called precipitous labor when it goes this fast, very overwhelming for mom especially. We wrapped her in warm blankets and I went to get some juice for her. Finally she could drink. She would need to replace all the blood she had lost and regain her strength. She was soon feeling much better and talking to her sweet little girl. Tamirat checked again as I replaced the baby’s damp blankets and hat with fresh warm ones and confirmed that they indeed had another girl. Little Selam would be pleased. They named her Negasi. I think we were all still stunned that she was here, that she and her mommy were OK.
            Tamirat asked if I would stay on while he went home for clean clothes and to get the car. He had come with her in the ambulance and didn’t have their hospital bag or anything. We relaxed and ordered a huge breakfast that was delivered shortly afterwards. Miruts told me she was actually feeling good, even after such a traumatic morning. Tamirat soon returned with roses and a big pink balloon with IT’S A GIRL! written on it, and a teddy bear, “for Negasi to give to Selam when she visits” he explained to me. And then he handed me a small brown bag with organic dates and a soy milk shake from a nearby coop. I was stunned! He had remembered what I had carried with me and ate a month earlier when we had met over the lunch hour one day on a home visit.
            The next day I went back to the hospital. We again talked about the birth. They were trying to process all that had happened. It takes time to take it all in and consider how it could have been different (it couldn’t, really) or better (we were very, very fortunate).
            During our prenatal visits I often brought my laptop along and shared some of the DVDs I have on baby-led breastfeeding or labor or natural birth. The last one I had shown Miruts was filmed in Brazil, I believe, about a midwife there who has discovered a way to foster the gentle birth continuum by her method of gently bathing newborns. It is at my blog for March postings, callthedoula.blogspot.com under the heading, The Best Baby Video Yet! It really is amazing. Since I first saw it I have been introducing this to new mothers and have the same results with each and every newborn baby. Miruts was anxious to try it, so we did – right there in the hospital the second morning, and just like in the video, her baby loved it, closed her eyes and actually went to sleep while floating in the tub! Some of the nurses asked to come and see us bathing Negasi and I am sure that was a first for them, too. Gone are the days that we subject newborns to the bed bath, scrubbing them from head to toe with a rough damp wash rag, taking extra care not to get the umbilicus wet (never mind it has been submerged in water for the last 9 months anyway) or her ears (ditto). We patted the umbilical stump dry and didn’t put anything else on it.
            And like in the video, Miruts massaged her baby slowly with almond oil while still on her towel. She enjoyed that, too, though decided it was time for lunch NOW, so we wrapped her in a dry blanket without any clothes and got her mom dry and back in bed, also without a gown (she had climbed in the bath first.) Negasi fussed until she was latched on once more and then blissfully went back to sleep. She even smiled for us at this point!
            Take a moment and think: we are the only mammals who dress our babies after birth. We are also the only mammals who ask ourselves, “Where will my baby sleep?” and “what should my baby eat?” Last year I found a wonderful talk by my favorite U.K. midwife, Carolyn Flint, (see: http://www.youtube.com/watch?v=PXCorYbsVfM)
who tells us that we “….should go home, if we aren’t already there after the birth and take all of our clothes off, and all of our baby’s clothes off (nappies or diapers allowed) and go to bed for 10 to 14 days with our little mammal.” Just consider: this gives mom time to recover and rest; baby can establish a good milk supply by nursing on demand; that bonding is optimum when there is uninterrupted skin-to-skin contact and the family can bond in the sacred space they have created in their bedroom. 
                       
** all names and identifying characteristics have been changed.
Stay tuned... This story is one of many that will appear in one of the upcoming books, Call the Doula!© and Stone Age Babies in a Space Age World: Babies and Bonding in the 21st Century©      both pending, by Stephanie Sorensen

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