Friday, May 10, 2013

Doula as Gatekeeper

Khou’s Birth Story*

Midwife: I would like to check to see if you have dilated.
#Vietnamese interpreter: Tôi muốn xem tử cung bạn đã giãn chưa?

Midwife: Is that OK?
Interpreter: Có được không?
My client only spoke Vietnamese, a beautiful first time mom whose water broke 2 days ago and who only this evening called me.

Midwife: Now, put your heels together and let your knees fall back…
Interpreter: Bây giờ, đặt gót chân của bạn với nhau và để hãy thả lỏng đầu gối
Midwife: You can relax ... that's better.
Interpreter: Đừng lo….. đúng rồi.
Midwife: Now you will feel my touch.
Interpreter: Bây giờ bạn sẽ cảm thấy tay tôi. I can only guess that she was either expecting labor to be contractions first, or a huge gush. A small tear high up in the bag of water can drip like a leaky faucet and was obviously not noteworthy to this mama. As soon as she called me I insisted on meeting her at the hospital and asked her to let her midwife know before she left the house.

Midwife: Now I want to put this speculum inside to look (holding the thing up).
Interpreter: Bây giờ tôi muốn đặt mỏ vịt này bên trong để xem.
Midwife: Sorry it’s cold.
Interpreter: Sẽ lạnh một chút.
Midwife: I will first test and see if this is amniotic fluid; this won’t hurt.
Interpreter: Đầu tiên tôi sẽ xem đây có phải nước ối không; nó sẽ không đau đâu.

This little exchange would all be fine and dandy except for the fact that the interpreter agency sent a male interpreter to labor and delivery that night. I can’t believe what I am hearing.

Midwife: All done.
Interpreter: Xong rồi!
Midwife: But your water has broken. It seems that it started 2 days ago.
Interpreter: Nhưng bạn đã vỡ nước ối. Có vẻ như nó bắt đầu từ 2 ngày trước.
Midwife: There is some concern that labor hasn’t started and we want to avoid an infection….
Interpreter: Tôi lo rằng bạn chưa lâm bồn và chúng tôi muốn phòng ngừa nhiễm trùng ....

When he walked into the room I had leaped off of my perch on a little exam stool by Khou’s bed, looked straight at him and said, “You and I will go BEHIND that curtain by the door and you can translate from there!” as I ushered him away from the bedside.

Midwife: So would it be OK if we started labor with something that will soften the cervix tonight?
Interpreter: Chúng ta có thể bắt đầu chuẩn bị sinh với cái gì đó làm cho tử cung mềm hơn tối nay có được không?.
Midwife: And hopefully get things going in the morning?
Interpreter: Và hy vọng có thể bắt đầu vào buổi sáng?

There was no way I would have him gawking at Khou lying there. I can’t believe they sent him!

Midwife: Yes? OK. I am going to put some medicine into your vagina and into the cervix. 
Interpreter: Có? OK. Tôi sẽ đặt một số thuốc vào âm đạo của bạn và vào cổ tử cung.

That’s IT! I am about ready to stomp out to the nurses’ station and demand a woman interpreter. How can they do this? I am furious!

Midwife: You will need to stay flat for 2 hours then. Do you need to go to the bathroom first? 
Interpreter: Bạn sẽ cần phải ở lại căn hộ cho 2 giờ sau đó. Bạn cần phải đi vào nhà vệ sinh trước không?

Why should you come to a foreign country and have to put up with this? I would feel so ashamed!

Midwife: Can you put your fists under your bottom so I can reach your cervix a little better?
Interpreter: Bạn có thể đặt nắm tay của bạn dưới mông của bạn để tôi có thể tiếp cận cổ tử cung của bạn tốt hơn một chút được không?

This is awful! He acts as if he does this every day. He does do this every day. She must be feeling sooooo embarrassed. The last time I had to throw someone out during a birth was when I worked at a free-standing birthing clinic and found both sides of the family of the couple in the kitchen smoking up a storm and setting up a bar. They were going to party until their baby was born! I tried to nicely explain that we weren't set up like a hospital exactly...we didn't have a waiting room and we would need the run of the whole floor so she could walk around during labor (much less any other clients who might show up that night to fill the remaining 2 birthing suites.) I suggested a motel down the road -- some of them had driven from more than an hour away -- so they reluctantly packed up and camped out in our parking lot for awhile, serving drinks from the car's boot until it started raining around midnight. We assured them we would have the couple call them when the baby arrived. BYOB to a birth. Really, now!

Midwife: Just breathe slowly. You will feel my touch now….
Interprer: Hãy thở chậm lại. Bây giờ bạn sẽ cảm thấy tay tôi ....

How humiliating! “You will feel my touch now…” his deep smooth voice coming from behind a flimsy curtain. This is like something out of a horror movie! I couldn’t do this! It’s awful!

Midwife: Just breathe slowly. Great. Thank you.
Interpreter: Thở chậm lại. Tuyệt vời. Cảm ơn bạn.
Midwife: I hope you can get some sleep now.
Interpreter: Tôi hy vọng bạn có thể ngủ một lúc bây giờ.
Midwife: I’ll check back in the morning.
Interpreter: Tôi sẽ kiểm tra lại vào buổi sáng.
One Friday night I brought my baby doll named Tofiq (toe-FEEK, an Ethiopian boy’s name,) a life-like 7 lb. African-American demo doll that was donated by an educational catalog company for my work with African refugee families in Minneapolis) to a women's shelter where one of my clients lives. The shelter is just for Ethnic women; there is that much domestic violence here in Minnesota to necessitate a culturally-specific shelter all their own!

We had been meeting for the past 3 months discussing her birth plan, and seeing videos together on birth and the stages of labor and breastfeeding , and going to classes about interventions and options. She asked if I had a camera and begged me to bring it to her birth. I promised I would.

Khou* though barely 18, had asked at our last appointment who was going to teach her how to bathe her baby when s/he is born, so baby doll and I arranged for a translator and we all crammed into her tiny bathroom that evening: Khou, me, Tofiq, the interpreter and the shelter director, a young social worker who had never bathed a baby before either, so she had asked to come, too. (See The best baby video yet! At this blog in the March posts.)

So I filled the tub, lined up the soap, shampoo, towel, and washcloth, and gave Tofiq a real bath, showing Khou how to first test the temperature of the water by dipping in an elbow and then how to support him in the water (he is even anatomically correct which sent her into giggles!) Then I had her do it all over again by herself. She did a great job until she laid him on the towel on the floor. I suggested at that point that her baby looked pretty cold to me. She quickly dried him off and wrapped him up in the towel and held him close, looking up at me for approval. I said he looked better, but, see his mouth is open (it really is) and that he is probably hungry. I didn't need the interpreter to repeat what she said then: “OH, NO!” as in, ‘what do I do now?' a look of panic spreading across her face. So we had a mini class there on the bathroom floor about how to get him in the best position for nursing: “Belly to belly, chest to chest… nose and chin should touch the breast!” Then she reminded me for the umpteenth time to be sure to bring a camera to the birth. I promised again that I would. I had to laugh seeing this teeny Oriental lady hugging a big Black baby doll to her breast.

Midwife: Now, put your heels together and let your knees fall back…
Interpreter: Bây giờ, đặt gót chân của bạn với nhau và hãy thả lỏng đầu gối
Midwife: You can relax ... that's better .
Interpreter: Bạn hãy thoải mái người…. đúng rồi
Midwife: Now you will feel my touch....
Interpreter: Bây giờ bạn sẽ cảm nhận được tay tôi....

YUCK! I am never letting this happen to one of MY ladies ever again! I hate this! Mental note: see nursing supervisor after this birth.

Midwife: Well, you have dilated to 5 centimeters! That’s great news!
Interpreter: Ồ, bạn đã giãn ra đến 5 cm! Thật tuyệt!

I rummage through the cupboards in the room until I find a dilation chart. I get the interpreter to explain what dilation is and what 5 looks like. Finally I can say, “You can GO NOW!” I point to the door and thank him. At last he is gone. It isn’t his fault. But couldn’t he protest? She could have been his daughter, for heaven’s sake!

Ok, breathe deeply. Relax. Doulas need reminding to breath slowly too sometimes, I guess. ARGH! I will explain myself in pantomime from now on if I have to and show her how she will open up the rest of the way until she can push her baby out.

The nurse wheeled in some kind of a Lazy Boy lounge chair and to my utter surprise made it up with clean sheets and pillows for me. Gosh! I could have done that. We finished the last of the snacks I had brought along and I went down to the nutrition room and got us hot drinks. Most hospitals will even give us doulas the door combinations to the kitchen or linen closet so we can help ourselves and take care of our moms without having to get a nurse every time. Warm blankets? No problem. Just dial 1532 on the door’s lock pad.

The rushes kept up for another two hours but eventually settled down so that Khou was sound asleep by about 3 a.m. I lay down and didn’t hear anything until she called me at 8:00 a.m. In her limited English she sheepishly said, “Stephy-ah, me hungry.” I stretched, got out of my little bed and fumbled around the bedside stand until I found the folder with the menu options and the extension to call to order meals. She knew the words for bread, eggs, tea and meat, so I ordered it. She again asked while we waited for her breakfast if I had the camera ready. I pointed to it right there on the counter. When the food tray arrived she dove into it. They had also included a blueberry muffin which is now her favorite food. She tried to order just blueberry muffins for lunch but we were told they are only a breakfast option. Later that day I let the secretary at the ward’s front desk know so she could make sure Khou got 2 blueberry muffins on her tray every morning while she was in the hospital.

No sooner than she had finished eating, the rushes started up again in full force (it is amazing what a little food and sleep will do!) and breakfast suddenly made a surprise appearance once again. I told her not to worry about it and helped her clean up and rinse her mouth. I told her what Ina May Gaskin says about this: that you actually dilate one centimeter every time you vomit during labor. It works this way because you can’t totally relax your throat and mouth without also relaxing the sphincter muscles down below. There is a connection: Wet your lips. Now just try to pooch your lips out and blow – we call it ‘horse lips’. Now, try to do a Kegel by contracting or pulling up on your bottom and the floor muscles of your perineum … hold it … and blow out through your lips again. It can’t be done at the same time. (Kegel exercises are used for strengthening your pelvic floor muscles.) You have to relax those muscles when you throw up and there isn’t anything that can’t be cleaned up in a few minutes. As a doula it is funny how fast you get used to these things. In spite of having just lost her breakfast, Khou cleaned up the last crumbs of the blueberry muffin and got up to brush her teeth and go to the bathroom.

Before long her labor was picking up speed beautifully. We stood, we walked, we sat on the birth ball (Khou did – I didn’t).  She asked for pain medicine at one point and asked about an epidural (and in the same breath asked if I still had the camera handy). The midwife said that she could get an epidural if she wanted it, but that she had other options too and suggested some fentanyl which would take the edge off the pain but still allow her to be up and moving around. She explained that it worked for an hour or two at the most. Khou said she wanted something and agreed to try it. She was very happy with the results and was able to rest. She asked again if I had the camera ready and I assured her I did as I pointed to it on the bedside stand. She closed her eyes and was able to manage the rushes better now.

She asked the midwife the next time she was in the room if Mary, the midwife she had been seeing in clinic was going to be at her birth. She was able to assure her Mary had been called. Khou again closed her eyes. We breathed through each rush and then rested. We were in a pattern now: breathe, slowly… blow it away… rest; breathe… slowly…blow it away….

Suddenly Khou’s eyes opened wide and she said, “I go toilet. NOW!” I knew this was the urge to push without even knowing if she was at 10 centimeters. The midwife with us did too and didn’t even check her cervix. Then Khou asked, “Where is Mary? I want Mary!” just as she walked in. She checked Khou and said, “Well, she’s complete. Can we get the room ready?” The nurses spun into action. The warmer was turned on. They checked the equipment, unfolded baby blankets and stacked up towels as Mary robed up and I tied the strings at the back of her gown.

We helped Khou lean forward from her sitting position and put a squatting bar in place while I stacked pillows behind her with one hand, the camera ready in my other hand. The nurse lowered the end of the bed slightly before the next rush. Khou flashed Mary a panicked glance which we recognized as the classic ‘tell-me-what-I-am supposed-to-do-next look.’ Mary smiled and told Khou that she was doing just great. She waited for the next rush and nodding her head said quietly, “You can push a little now.” It took a few more rushes for Khou to get the hang of it but very quickly the little head was crowning. Then baby literally dropped out onto the end of the bed during the next push, completely surprising Khou. If looks could talk I would swear she said, “Where did THAT come from?!” And I did get pictures – lots of them.

I voiced my complaint about the male interpreter as civilly as I could manage on my next trip for coffee as I passed the nurses’ desk and was able to get a woman interpreter for my postpartum visit the following day. I had waiting at my bus stop in the snow earlier that morning in front of a florist shop. It occurred to me that no one would be bringing Khou flowers after all her hard work. If I had the money, I pondered, I would have loved to have bought her a huge bouquet but I had just spent the last of my savings unexpectedly the weekend before in order to attend a funeral in Seattle. Friends of mine had lost their 19 year old daughter in a tragic accident while she was visiting friends in Taiwan. It was a sad trip and I couldn’t say anything that would take away their pain, but I hope just being there with the hundreds of others who came would give them strength for the days and weeks and months ahead.

I thought of my friends in Seattle once more as I walked into the room. A young nurse was just arranging a beautiful little arrangement of pink tea roses on Khou’s bedside table. It was this nurse’s birthday and someone (special, I could imagine) had flowers delivered to her at work but she said she wanted Khou to have them. I had never seen such an act of kindness as that in a hospital before.

I asked Khou if anyone had explained how or what they had done to fix her tear after her birth. She shook her head. I know she had been quite mystified by everything at the time and knew she could not take in one more thing, so I postponed this discussion until now. At the time her midwife had simply explained that she was going to repair a tear though I doubt any of this registered with Khou then. I brought along my sketch pad and drew a picture of her anatomy at the time of birth, explaining how the baby’s head was stretching her vagina as she crowned: 
Then I drew a picture of what it looked like after birth with the tear along the vagina’s back wall. I explained that Mary had used a round needle to first pull together the underlying muscle, pushing everything back into place there and then closed the tear with small stitches along both edges of the torn skin. I told her that the string is a self-dissolving material so the stitches won’t need to be removed later. Then I told her that her midwife is a real artist and that she looked absolutely beautiful down there. She questioned the interpreter if she had heard that last comment right and I assured her that she had and that I had seen lots of women so I should know!
At this point another nurse came into the room to do a blood pressure and stopped to look at the diagrams. She glaced at Khou and then back at me looking very puzzled. I told her that no one had explained to Khou what had happened or why, so I was taking the time to show her what had gone on ‘down there’. I added, “I think she should know what happened and understand what was done to her own body.” This seemed to be a completely foreign concept to this particular nurse. Should a young, homeless, illiterate, refugee woman be treated any differently from you or me?

Another thought on the bus on my way home: what if we had gotten a male midwife? Or if the only resident on the floor was an African American and I knew that my Asian lady was not assimilated enough yet to be OK with that because no one in the jungle village of Phongsali where she comes from had ever seen a Black person? Should I just chalk it up to her American education or make her as comfortable with each member of her team as I am humanly able? Would they understand? I am not sure yet what is the better course. More to ponder…. I will throw this one out at our next doula meeting.

*All names, places and other identifying characteristics have been changed to protect privacy

** Heartfelt thanks to Vu Nguyen, University of Minnesota, Minneapolis for his excellent translations for this article!

COMING SOON: This and other stories will be appearing in either 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

When you were born, you cried and the world rejoiced. Live your life so that when you die, the world cries and you rejoice. - Cherokee

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