Wednesday, May 1, 2013

Call the Doula! a diary ~ May 1st An Unplanned Natural Birth

I am given a new referral. Another mom whose OB has concerns about a big baby. Doesn’t speak English. Has serious diabetes. Gravida 2 (a history of having had 2 pregnancies so far, this one included). Not due for another week and a half. The midwives at her clinic have had to refer her to an OB. He suggests an induction. We are now on a high risk track. Again. Ugh.

Many of the women at this clinic are recent refugees from Ethiopia. (There are over 80,000 African refugees in Minnesota at this time, not to mention an additional 50,000+ Southeast Asian immigrants here too.) All of us hope to make their experiences of pregnancy and birth in their new country a positive one. We have all read everything out there about cross-culture medicine and tried to learn from the earlier mistakes made during the beginning of their assimilation. One of my favorite resources is the book, The Spirit Catches You and You Fall Down, A Hmong Child, Her American Doctors, and the Collision of Two Cultures, a brilliant, timely work by Anne Fadiman, first published in 1997. All of the universities and medical school programs in Minnesota now offer and require courses that concentrate on helping us understand the barriers facing diverse immigrant communities in our state, which include especially cultural and linguistic challenges.
In Minneapolis alone more than 66 distinctly different African languages are spoken in the public school system, just to give you a glimpse of only one of the challenges facing us. I didn’t know there even were that many African languages. I didn’t know that French is the official language of Togo, (and I failed French twice in grade school, though I have since learned Chinese Hmong and Korean and can get by in Spanish.) I have to confess I even had to find out where Togo is. Ghana is on its left, and Benin and then Nigeria are on its right, just above the equator on the far western coast, under the big rounded side on the left of the African continent. It also borders the Gulf of Guinea in the southern part of the Atlantic Ocean.
I met Ayana only a couple of weeks ago. She had not attempted to get prenatal care until her 8th month, even though she had state-funded insurance to cover her throughout. Coming from a district in Ethiopia that doesn’t have a medical facility left many of the community unaware of the concept of preventative medicine and how it can affect the outcome and improve pregnancy.
During our first visit I explained what the role of the doula is prior to and at birth. She said she was delighted to have so much help as her own family was not in the U.S. She had few female relatives here and her husband had said that his job would be to watch little Omar, their very energetic 2 ½ year old boy while she was in the hospital. It is a pretty universal assumption in traditional African society that birth belongs to the realm of women and that men are not especially welcomed. One father from Cameroon actually took the time recently to sit me down and explain to me that African men don’t like to see their wives “like that” meaning sweating and pushing their babies out, and that we would do well in American to explain this to our husbands and perhaps they would respect their wives more and there would be far less divorce. I didn’t agree nor disagree but just listened and said, “Oh, uh huh. Hmmm,” -- my pat answer when our cultures clash but I don’t see any point in trying to correct what I perceive as error quite yet. Perhaps later there will be an opening to discuss this. He wasn’t ready. And if I wish to continue working with families from another world other than my own, I have learned that I get a lot more mileage from coming to this work with respect and humility than attempting to confront my perception of the differences. A very wise, timely saying from the last century that I believe is attributed to Chief Seattle says,
Do not judge your neighbor until you walk two moons in his moccasins.”
With that premise I must allow the possibility that he might even be right! So, we will begin preparing for this birth now, however late it may seem. I often meet with women at their clinic appointments. I get a lot of ‘no shows’ if I schedule our meetings outside of other commitments. I am not sure why, though I can guess that with little kids, in a new country and the language barrier, and learning the bus system if you don’t drive, meeting with your doula or midwife for that matter isn’t on the top of today’s to-do list. Just getting to your English class, getting the groceries home, and picking up a kindergartener after school is mind bobbling enough.
At our first meeting I show a wonderful little DVD called Doula that was made here in Minneapolis recently. It is perfect for the population I serve: Not only are there women of color having babies in the film, but there are home births, hospital births, footage of C-sections, water births, hands and knees births and even mamas picking up their own babies at birth. Equally important (though I am sure that the women who made this beautiful film may not have realized it) is that my mothers can see women in American giving birth completely au natural, some wearing nighties, others have their partners in the tub with them – the options are endless. This is important because I want them to know that the birth room is THEIR SPACE, that they will own it and they can do whatever they instinctually need to do to birth this baby and don’t need to worry that there is a certain way they have to conform to, like they have to do every single other day in American society; here they can literally let their hair down – or their hijab! (the Muslim women’s head covering.)
After we watch the movie I often wonder at the look of awe I see. This has opened up a whole new world of possibilities to many of these women. They are being put in charge of something for the very first time since coming here and I articulate it this way: “This is YOUR birth. It is YOUR body and YOUR baby. I will not be making any decisions for you but I will support you throughout your birth. I will not leave at shift change when you get new nurses and often a new midwife or doctor. I will be your advocate for whatever your wishes are.” This is a scary prospect to some. It is exhilarating to others. For every one of these women though, it is a new concept. They are in charge. They are often liberated by this one experience alone.
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
The next step is to write a birth plan. I have one that I wrote that I give them suggesting they edit it, completely rewrite it, or throw it out and tell me what they want it to say instead. The interpreters at the clinic can help us with this, too. Recently, when I showed the Doula film at a clinic, the interpreter started crying! She just found it so moving and so different from what her own births in this country had been like.
The birth plan is one page long. I have seen templates for birth plans on the Internet that are 9 pages in all. From my experience, no nurse or doctor will sit down and read anything longer than one page. They don’t have time, and I do not want them to skim over it either. Since it is part of my job to greet anyone who comes to the room I immediately introduce myself and then invite them to read our birth plan. It sets the tone that says this lady knows what she wants and has definite ideas. It says that she has wishes and choices and implies that because I respect that, we expect they will too. It sends a powerful message, I believe.
We usually talk about each entry on the birth plan and what each option means. After we write it, I go through a little exercise I learned in my own Doula training at Enlightened Mama in Minneapolis. See: I suggest she look at her birth plan and if she absolutely had to, decide what 10 items would she keep and which would she be able to let go of? Then, which 5? And then all but one. We don’t have absolute control over how our births will go. This is our first test in the journey of parenthood. It is about what is best for my family, not my mother or my midwife. I believe there is a greater dissatisfaction with our births when we cast our birth plan in stone and then feel like we failed if we weren’t able to do everything the way we had planned. This is a sample of what I like to start with:

Laura’s Birth Plan

I would like my partner to call Stephanie 612-232-2323 when labor starts. I want to labor at home as long as possible.

Who I want in the room: If any residents or students wish to attend our birth, please check with me first. I want my partner and my doula in the room with me at all times. If anyone else arrives at the hospital, please ask me first if I would like them present.

What I want: I want to walk, use the birthing tub, birth ball, etc., and move as much as possible during labor.
I want to eat and drink and wear my own clothes and not be offered pain medication. I will ask for it if I need it.

What I don’t want: to be asked what my pain level is. I will ask for medication if I need it.

I don’t want nurses shouting to push or counting out loud. I want to push with the urge and work with my doula during this stage.
I do not want continuous monitoring but prefer a portable Doppler.

I do not want the bag of water to be artificially ruptured.
I do not want an episiotomy. I would rather tear. I would like my doctor/midwife to use oil on my perineum to help with stretching.

When my baby comes, I want to hold her as soon as possible.
Please delay cutting the cord. Then I would like my partner to cut it.
I want my baby on my chest and to let her initiate breastfeeding. My doula will work with us on baby-led breastfeeding.

I want her weighed and measured and any care done while on my bed after about 2 - 3 hours of bonding.
I want my doula to help me give my baby her first bath in our room before we leave the hospital on day 2.**

I do not want her going to the nursery at all. We will room-in.

I do not want her given formula, sugar water, or pacifiers.
I want Vitamin K and eye drops given after she has been with me for about 2 - 3 hours. I want to hold her for the Vitamin K shot and later also for the PKU.
I will go with my baby to have her hearing screening done. I want to bring my placenta home.

Thank you in advance for your help and consideration!

Ayana’s doctor scheduled an induction for the following week. The sugar levels and insulin were his main concern. Also her first baby had been only 6 pounds but this baby was much bigger. We met at the hospital and walked up together. She told me that she had just decided on a name: Sisay. She said that in Ethiopian it means ‘an omen of good things’. When we were settled I filled out the white board in her room: baby’s name, mom’s name, doula, interpreter, etc. The Amharic interpreter that came that day is one of the most amazing women I have ever met. Radiya left Ethiopia and moved to New Delhi, India 6 years earlier, all by herself. A traditional Muslim woman, she had earned a master’s degree there in business administration. Then she moved to the U.S. and took a course in medical interpreting and got a job with an agency that serves the hospitals in Minneapolis. This was my second birth with Radiya as an interpreter and we were both delighted when we saw each other again. I had been emailing with her and encouraging her to continue her education. Together we are looking into midwifery programs for her. We desperately need women like her in the birth community. She has a heart the size of Texas and is a natural from all that I have seen.

The induction started out slowly. There were mild contractions and she was dilated to 2 centimeters for the first two hours. I was glad that they encouraged her to eat and walk around. By early afternoon the contractions had stopped. Time for a snack and a nap. The doctor came by and suggested trying some Pitocin next which Ayana agreed to. The rushes picked up slowly and finally we thought that they had gotten a nice pattern when the nurses saw that they were actually coupling, or coming two at a time with longer rests in between. Then the rushes are neither very effective nor helping the cervix to dilate, so the Pitocin was stopped. The doctor suggested that Ayana rest, have supper and then suggested using a medication called Cervidil§ that would help ripen the cervix so that either contractions would establish themselves, or if they had not by morning, then the Pitocin might be more effective. She thought this all sounded OK, though not our plan, but I was glad the doctor was not being more aggressive and actually rather reserved from what I have seen in other hospitals.

By morning Ayana felt much better. Contractions were weak, though regular. Pitocin was started again. Pretty soon we were in business: 4 centimeters and she wasn’t laughing at my jokes any more. This is Active Labor and serious business. We walked and danced a slow version of a belly dance with me humming along while we bonded with walls up and down the four halls framing the unit. On this floor no one looks twice at couples frozen in place as if in an adult game of STOP! I suggested different positions: hanging while holding onto my shoulders, leaning into the wall, squatting by the bed, sitting on a birth ball, and hands and knees. We tried the tub for a while, but Ayana liked walking best. Every time we completed a 4-hall lap, we would stop by her room for a potty stop and another cup of juice.

We didn’t need a nurse to check to know she was opening up. The rushes were closer now and Ayana asked for an epidural. I explained some of her other options, but she had had an epidural with her last birth and had written that into her birth plan this time. Although I would love for every mom to explore natural birth, I have a strong commitment to supporting each one in whatever way they feel is best for them. I can only hope that they will gain strength and confidence with each birth and perhaps consider using less conventional methods in the future. They know I am there for them unconditionally and will not criticize their choices or continue to push in a direction they have decided is not what they want. So I let her nurse know that she was asking for the epidural. She called the anesthesia department with the request and set the room up for the procedure while we continued walking and drinking juice (I was pretty sure they would not let her do that once the epidural was in place. It is usually ice chips only at that point.)

Fifteen minutes later Ayana asked when the anesthesiologist was going to come. The nurses assured her that he was on the way. Half an hour passed and we were doing some pretty heavy duty breathing now. At one point I looked over at the nurse who shrugged her shoulders, looking baffled, too. Where were they? Ayana was obviously miffed at this point and had not planned on this at all. I kept telling her how strong she was, and how well she was doing. I helped her rest between the rushes, but when each one crept up on her again and then quickly intensified, she repeated her little mantra: “When? When? When?” Finally another nurse came in and very apologetically told us that he had been called away to an emergency and will come as soon as possible. I silently wondered why only one anesthesiologist was in the hospital, but I didn’t want to do anything to further disturb our routine at this point, so we continued breathing and resting… slowly... breathing… and resting. Radiya and I were both kneeling on each side of Ayana who was sitting in a rocking chair when all of a sudden she stood up and said she had to go to the bathroom. We had just been so I knew this was the beginning of the urge to push. I was surprised that Radiya could also read the signs and quickly instructed Ayana to sit on the bed where we could help her better. As we got her more comfortable I hit the nurse button said as quietly as I could, “we are thinking about pushing in room 350.”  Sure enough with the next rush Ayana flashed a panicked look at me and then took a deep breath as I did and pushed… and pushed. The doctor ran in the room between two nurses who were pushing in the warmer and instrument cart. Another push and we could see lots of baby’s head. Another grand push and she is here! Ayana looked down and just sobbed as she reached for her baby who was already crying. We got them comfortable while we waited for the placenta. Ayana’s look of absolute shock sent Radiya into another gale of giggles. I told Ayana how amazing she was. I also told her that now she could do anything! It was obvious that she couldn’t believe she had actually had a baby without any medication. We told her how strong she really was. I only found out the next day at our postpartum visit that she is a single mom. Recently divorced, her ex had offered to watch their son when she went to the hospital, but had no intention of helping her further.

In some larger, cosmic plan I believe this birth was meant to be this way to prove to Ayana that she was capable of anything. I think she can now agree, too.

I stay for 2 more hours and marvel at how beautiful little Sisay is and at her courageous mother. Another amazing birth I have been blessed to witness!

I am finally home and soaking in a deliciously hot bath tub. My husband heats up some food for me and has it ready as I sink into the couch next to him just in time to watch the next episode of the BBC's Call the Midwife! together.

(I didn't make that up. It is really true!)

§Unlike Cytotec, a very dangerous drug that is still being unscrupulously used throughout the U.S. and the world, Cervidil is successfully used to aid induction if truly warranted. Cervidil comes in a tiny rectangular pouch with a retrieval cord that looks similar to a tampon. It is inserted into the vagina, and contains prostaglandin, one of the chemicals that play a part in ripening the cervix. A ripe cervix is soft and stretchy, ready to respond to uterine contractions. Cervidil is used to "ripen" the cervix when it is agreed that your baby is safer to be born than to remain in the uterus. Cervidil is the first step in a two part induction process when the cervix is not ready to respond to contractions. Cervidil may increase the activity of non-productive contractions when no other labor stimulation agent has been used. Cervidil allows the mother to use the medication for the prescribed amount of time and then remove it. In some cases a mother may be able to go home after administration to wait for labor to start. Because prostaglandin E2 helps to make the connective tissue of the cervix more pliable while also stimulating contractions, it is more effective than synthetic oxytocin at inducing labor. The rates were similar for women giving birth within 12 hours, but more women had given birth within 24 hours with prostaglandin and the difference is even more pronounced at 48 hours. In addition, the rate of instrumental vaginal delivery is lower with women induced with prostaglandin E2. Some risk factors include side effects such as nausea, vomiting and diarrhea. There is a small risk of uterine hyperstimulation. It also requires continuous monitoring of baby's heart rate which decreases the mother’s mobility. Occasionally it causes abnormal fetal heart rates.

*all names, ages and identifying characteristics have been changed.
** see “The best baby video yet!” Listed under March at this blog.
COMING SOON: this and other stories will be appearing one of the books, Call The Doula! a diary, or Stone Age Babies in a Space Age World: Babies and Bonding in the 21st Century,© pending by Stephanie Sorensen

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