Sunday, June 2, 2013

All in a (Doula’s) Day’s Work

“Waking up this morning, I smile. Twenty-four brand new hours are before me. I vow to live fully in each moment and to look at all beings with eyes of compassion.” 

― Thich Nhat Hanh 

First babies are often slow in starting when it comes to labor. I tell moms that their muscles know they must practice ahead of time because they’ve never done this before. So even two or three days of prodromal labor is normal. It can come on gently and then stop. Or labor comes on strong and then stops. And tries to start again, only to stop again. The trick is not to worry. (Yeay, right!)
The traditional midwife believes that birth proceeds in a spiral fashion: labor starts, stops, and starts while the baby goes down, up and down, and the cervix opens, closes and opens. Nature has no design for failure; she holds her own meaning for success. 
~ Sher Willis

From the expert, Gail Tully, See

She writes: There are variations in early labor patterns. Early labor is from 0-3 cm dilation by common childbirth education descriptions. Next comes active labor from 4-10 cm, including contractions, or rushes, that come on stronger and more frequently and last longer.
            Prodromal labor is when the uterus contracts somewhat frequently, may be strong or mild, contractions usually aren't occurring with regular intervals, but can keep a woman on alert, can keep a woman awake, and certainly can keep everyone wondering when active labor will establish.
            Typically, primipara (a first time mama – ‘primip’ [PRIME-ip] for short) women are told that labor begins gently; contractions may be 10-20 minutes apart and gradually grow closer and stronger. Once the cervix begins to change, to dilate and thin out, labor is considered to be starting.
            Women may be told that ~
Early labor can stop without it being a matter of concern. In fact, it is often considered
quite normal. Interruptions in location (going from home to hospital, for instance) or people (the nosey neighbor, stressed family member or unfamiliar medical person) walk in or leave (partner, doula, supportive nurse, doctor, or midwife has to leave for some reason or end of shift). These can be thought of as psycho-social reasons for early labor to stop. These reasons are well known and talked about in childbirth classes, for instance.
            Prodromal labor may start with the night and stop with the day. Non-dilating contractions seem more common with approaching storm fronts when the barometric pressure drops. With or without contractions, a woman is considered to be early labor if a woman's waters release (Spontaneous rupture of the membranes, SROM).
            Women aren't usually told that  ~
Early labor can stop when the uterus gets tired after trying to fit the baby into the pelvis.
Which may be because baby isn't engaged yet; often because baby is posterior and, in this case, the head may be deflexed (extended, chin up) and the forehead is resting on the pelvic brim, and not engaged. Early labor with a breech baby can stop/pause when the baby is trying to tilt his or her waist to get the hips into the pelvis. The labor may stop at any point with any fetal position if the baby can't fit further down the pelvis and the uterus gets tired. Rest and food may also help solve any problems.
             Hormones increase at the end of pregnancy helping prepare for actual labor. A rhythm of coming on at night is often hormonally related. These "practice" contractions are often called Braxton-Hicks. They can be painless and thought to be the baby moving or "balling up," or they can be quite intense making a woman feel that she will have having the baby that day. The thing is these don't change the cervix. Don't be shy about checking in with your provider. Better safe than... surprised! 
            Labor comes on strong and then stops. And tries to start again, only to stop again.
Sometimes these are simply warm-up or practice contractions as described above. But when they begin in the daylight or after fetal movement, and don't change the cervix, then consider if the baby is 
  •  Trying to change position, from posterior to anterior or breech to head down, for instance
  •  Successful at changing position (though it may not be the position you hoped for, so check it out)
  • Trying to engage in the pelvis
            Zoë* is a very courageous single mother. She called me sometime during the night on Friday. I don’t look at the clock any more when the phone rings. My night is over no matter how much or how little I’ve slept, so I let the adrenaline take over. I am being blessed with being asked to attend yet another miracle. I am grateful and a bit in awe each time, even after 30 years. It is actually the most important event at this moment in the entire universe, and I get to see it! Rather, I look to see whether or not I laid out a clean set of clothes on the chair the night before and that my bag is packed and standing by the door.          

Her contractions were strong enough that she couldn’t sleep but nothing else was going on. Her water had not broken yet. Zoë’s visit with her midwife the day before confirmed that she was starting to dilate a little and was at 1 centimeter. The midwife was concerned that the baby didn’t appear to be very big and may not have grown in the last couple of weeks. She ordered an ultrasound at which the technician guessed the baby was about 6 ½ pounds. She sent her report back to the midwife saying that all looked well in there. There was also some worry that Zoë’s blood pressure was slightly higher than they would like. The midwife had already started talking about inducing her should the blood pressure stay too high, or baby appear to have stopped growing and might do better outside rather than in at this point.
            I told her that it sounded like this might be the night. It was 1 day past her guess date (no longer called a due date because too many pregnancies were being induced when in fact babies weren’t ready to be born and sometimes 1 or even 2 more weeks was needed for this particular baby.)
            I encouraged her to try to sleep, even if she just dozed. I told her that if she slept and the rushes went away then we would know it was just early labor. I said that if they picked up and became more regular or her water broke that then we have the real thing. I also advised her to let her midwife know and to let me know if she wanted her to come in yet. I went back to sleep and didn’t hear anything from Zoë the rest of the night.
            I assumed that things did settle down. I texted her about noon and got a reply that the rushes were still very sporadic but she was visiting friends and walking a lot. Later that night she called asking if she might be seeing the mucus plug, or bloody show, which I confirmed. I told her it was all completely normal and that she should try and nap and to keep eating.
 Finally at 10 p.m. Zoë called to report that the rushes were about 5 minutes apart and that she couldn’t keep it together alone at home any more. I suggested she call her midwife and let me know if she would be going to the hospital. I offered to hang out with her at home, too, if she wanted to do that.  She called back within minutes and said they wanted her to come in. She suggested calling me after she got there to see if they really were going to keep her or send her home. A bit later she called again and said she was at 3 centimeters but that her blood pressure was high and they wanted to keep her and monitor that. I was on my way.
            During the night the nurses had her stay in bed hoping the blood pressure would come down. It did for a little while, but then when the rushes got more intense it rose back up. We tried different positions in bed that might help the baby labor down even if she is not able to walk around. Sitting up in bed cross-legged, on all fours or on her knees with her arms resting on the raised head of the bed, or lying down with a peanut ball between her knees all encourages the baby’s descent. 
            Finally she got to 8 centimeters at about dawn. We were able to move to the tub at this point which Zoë said felt wonderful compared to the bed, but even after more than 2 hours, we were still at 8 cm. The midwife suggested breaking her water to help the baby’s head press against the cervix, hopefully encouraging the last 2 cm. There was some meconium in the water, so at the midwife’s insistence, we went back to the bed and the monitor to see if baby was OK. The fetal heart tones were not ideal, so they watched that for a while. The blood pressure was still too high for comfort, but the midwife was quite relaxed and didn’t suggest any interventions yet, which surprised me. Most of the other hospitals I have worked at would be talking about a C-section by now if that had not already happened.           

The shift changed. New nurses fluttered in and out of the room. We were still at an 8. By 8:30 a.m. Zoë had been up two nights and three days and announced that she was done in. She asked for something for pain or something that would let her rest for a while. The nurse called the anesthesia department and set the room up for an epidural. I got Zoë up to the bathroom and suggested she stay there for a bit. It is an ideal position to labor in on a toilet and she felt better being up so we hung out there. When she returned the anesthesiologist ran through his list of dire side effects, had her sign the consent form and then sped through the screening questions. He asked at one point, “normal blood pressure?” and since Zoë was in the middle of a rush, the new nurse answered for her, “Yes.”
            I was surprised and hesitantly added, “Um, NO!” He turned to the nurse who explained that it was high when she came in but it was fine now. I was shocked, knowing that it was higher than any protocol that was in place when I was still a practicing midwife, so I ventured out again and said, “Well, actually, it is not normal. It has not come down. The last one was in the 150s.” The nurse huffed; the doctor looked at her and back at me, quite befuddled. Then he said, “OK, let me see the (monitor) strips then.” He carefully unfolded the strips from the previous night and noted the elevated numbers and announced, “No way!” The nurse looked too and said, “But no one told me!” This obviously got missed at the report at shift change. She should have been alerted but wasn’t. I wasn’t overly upset; I knew we were all part of a team wanting the best for Zoë and we need to look out and cover for each other. So, the doctor ordered a blood test that would tell him if she was indeed pre-eclamptic or where she was at. I knew she wanted some pain relief so I asked him if he could recommend something while we waited for the blood tests to come back, which I knew could be quite a while. He suggested fentanyl which the nurse ran to get. She gave that to Zoë who was still trying to work with the rushes and trying to follow my breathing but was very impatient at this point for some kind of a break.           
          The fentanyl didn’t do anything. Zilch! I had never seen that. It usually helps women relax almost immediately and some people actually feel rather happy or even goofy on it. I tell them that I promise not to repeat anything they say from here on out, since it is known for its somewhat drunk-like-inducing properties. It doesn’t take away the pain, but it does take the edge off for an hour or sometimes two and then can be given again if needed. But we had to work with each rush just like we had been doing. This was a first for me. I didn’t say anything to her, but concentrated on staying connected and reminding her to rest between each one. While we kept on dealing with each rush and then resting the doctor left, the lab people left and the nurses all filed out, leaving us alone.
            I look back and wonder if her full bladder had slowed things at 8 cm. or if just getting up and sitting on the toilet at that particular moment did it, but as soon as the room was cleared (taking with them all the concerns and negative vibes) Zoë announced she wanted to push! I completely trusted her instincts on this one, even though she was only 8 cm. five minutes ago. I suggested just some tiny nudges on the next rush. She tried that and I could see baby’s long black hair. I called the nurse who hit the “COME ALL” button on the wall as soon as she saw it too. Two more pushes and baby was on the bed. Zoë was reaching for her, crying and overcome with joy. Baby’s cord was too short to let her be lifted up to Zoë’s chest, but as soon as it stopped pulsing the midwife cut it and baby was with her mama. She nursed shortly after, without even showing her how. Little Jazelle was 6 pounds 5 ounces, and 19 inches tall -- not overdue at all. No long fingernails  and plenty of vernix, the creamy coating that prevents babies from turning into little prunes from being in the water for the last 9 months. It is a waxy white protective substance covering the skin of a fetus, short for vernix caseosa. Her little ears were still stuck flat against her head, another sign of prematurity, or in this case, not being ‘overdone’. Overdue babies’ ears often stick out and the placenta will also show signs of aging if truly overdue.
              We had worked out a birth plan ahead of time and stipulated that we would like baby with her mom for at least 2 hours after the birth and after that any care would be done on the bed and baby would not be removed to the warmer or nursery. I find that nurses actually like this plan as it gives them more time to pick up the room and not feel the pressure of having to finish every last item on their to-do list before they can leave after that shift. They can simply note in the chart that the mom ‘refused’ all the routine
procedures after birth like weighing, measuring, eye drops, vitamin K shot, etc. It lets the nurse off the hook and the next shift can fit it all in at their convenience instead. So that is what we did. Just hang out and get to know Jazelle. And order Zoë a big breakfast. She wasn’t able to eat during the night – standard procedure for labor and delivery units, especially when they have concerns like meconium or high blood pressure. This puts the mom on a fast track to the possibility of a C-section and you can’t have any food in your stomach for that, so it is pretty common to have to switch to ice chips and water when interventions first appear in the conversation. Needless to say, she was ready for a couple thousand calories, after all, she had just consumed as many calories as she would have running a marathon! We called down an order for just about everything from the breakfast menu which arrived shortly after.
            I finally got ready to go. I packed up the tea lights, massage tools, snack boxes and juice bottles and hugged Zoë goodbye. I whispered in her ear, “You got the natural birth you wanted in spite of everything! I am so very proud of you, sweetheart!” We agreed to get together as soon as she got home for a postpartum visit. Another happy motherbaby couple. We are actually beginning to write 'motherbaby' as one. Stop and think about it: they have been one all these months, and that bonding continuum should be ongoing during the next weeks and months. Our babies are not born mature enough to be without us at all. They are totally helpless, far more vulnerable than any other baby mammal at birth.          

Have you ever wondered why we as humans have such large brains? This one is obvious: we are smarter than any other animal. But our babies are more helpless than other mammals at birth. Have you ever wondered why? Part of the reason is that, yes, we are the most intelligent species, but our babies are born unprepared for survival. Our brains grow so fast before we are born, and into the first year, however, that if they kept growing until the rest of the body caught up and was as mature as, say, a calf is at birth, their heads would be far too large for the birth canal they must pass through. Since our brains are so advanced, they grow faster in the first year than the brains of any other species. If we waited another 4 - 5 months or until they could crawl, to deliver our babies their heads would be too big to fit our frames. So Mother Nature had a toss-up: make mothers’ hips even bigger than what we have now (Horrors!) or have babies born sooner than they are in reality ready for. So, this makes it clear that they are not as mature as other little mammals and do need us constantly, even more than the offspring of other species. Nature knows this. Babies know this. Do we? We don’t act like we know it. Nature knew also, by the way, that baby elephants would not survive if they couldn't walk and keep up with the rest of the herd shortly after birth, and would likewise be eaten if left behind, so elephant mamas are pregnant for 2 years or until baby Babar can walk! And we complain about our 9 months' gestation. (A MUST see: The Dramatic Struggle for Life - Bali, on YouTube)         

     It is actually an illusion to imagine that our man- or woman-made time machine should likewise affect our babies, but we in fact do believe this. The truth is our babies are just about as immature at birth as our fore-mother Lucy’s were 3.18 million years ago. Consider Lucy (who currently resides at the Ethiopian National Museum in Addis Ababa, Ethiopia), whose babies had to be carried, and in constant contact with her, 24 hours a day, day and night, for at least 2 years or until they could walk. He (I am just guessing it was a firstborn son) had constant skin-to-skin contact; was in constant proximity for eye contact with his mother or whatever member of the clan his mother was interacting with throughout the day – at an adult’s eye level, incidentally, and not lower as in a crib or stroller where faces suddenly appear to loom above his and just as quickly disappear.  He nursed on demand.  He had no need to cry. A grunt or his reaching for a breast would be enough of a sign. His mother had enough time connected to him that she could already easily ‘read’ any signals coming from him. He listened to his mother interacting with others all day long. We don’t know when she began speaking directly to him, though. Perhaps it began when he spoke first, having listened to adult speech and figured out how it worked.
          We now know that bonding is reciprocal.  Even into the 21st century, however, we can read some authors who are still considering bonding a mother-led phenomenon, whereas it is actually reciprocal. When a baby searches his mother’s face, he is seeking her gaze in return. If her gaze is not there more times than it is, she has also given him a clear message: this is not how we humans interact, though she gives him no alternative solution. When he reaches out to touch her, he expects his hand will be held or caressed. When he first coos, a rewarding sound from his mother will encourage more early speech. If parents are engaged elsewhere either mentally or literally, while interacting with a cell phone or texting, for example, and those overtures from your baby are ignored, that, too, is a message: he isn’t being answered. Perhaps his voice may not be the best way to communicate after all. He’ll have another try at it first: cry louder, perhaps, to get the needed response. Or do something, anything, to get your attention. Sounds familiar? But back to Lucy. Bonding was the way to survival. Had she put her babies down, they would have been mauled or eaten. And we would not be here today.
           I got home that afternoon to a flurry of activity. A dear friend had called my husband while I was at the hospital in Minneapolis asking us to go to South Dakota as soon as possible as a friend of ours was in intensive care in a coma from spinal meningitis. A young father in his 40s -- we couldn’t imagine what his wife and 15 year old daughter had been going through. We didn’t even know yet if he would make it through this. We packed up, I showered and changed, threw some food in a bag and we left, driving non-stop till we got to Sioux Falls. He had come out of the coma while we were driving, though he was very confused and still critically ill. He turned a corner later that day and has been improving little by little ever since. He is not out of the woods yet or the ICU, but he seems to be mending. We are all so grateful.
          We returned a couple of days later and I could finally visit Zoë. I didn’t recognize Jazelle – I had only seen her while she was still nursing and had not been cleaned up at all yet after the birth. They both looked so good. Zoë had support from her family and friends and was still floating on cloud nine. She could not believe how intense and how incredibly amazing her birth was. With your first you can watch dozens of videos about birth and read all sorts of books but nothing really prepares you for the experience. I told her I knew she could do it and that now she knows too, that she can do anything. It was a very empowering experience for her. She will need that inner strength now to raise her baby girl on her own.

“People usually consider walking on water or in thin air a miracle. But I think the real miracle is not to walk either on water or in thin air, but to walk on earth. Every day we are engaged in a miracle which we don't even recognize: a blue sky, white clouds, green leaves, the black, curious eyes of a child -- our own two eyes. All is a miracle.” 

~ Thich Nhat Hanh

*all names, dates and identifying characteristics have been changed.

STAY TUNED... This and other stories will be appearing in 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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