Monday, July 29, 2013

Being a Doula for a Doula

When the referrals for expecting moms comes in to Everyday Miracles ( it tells us only the barest of information on the woman. We see her due date, whether this is a first baby, if she is eligible for a car seat and breast pump through her insurance, what hospital she has chosen, where she is receiving her prenatal care and often not much more than that. Occasionally there will be a note, for example that she is in a methadone program, or that she doesn’t speak English. Our secretary will call the mother and explain a bit about our doula program and confirm that she would like to participate. So when I received Jessica’s referral it didn’t say a whole lot. I called her and set up an appointment for the following week at Everyday Miracles where she could attend childbirth education classes, yoga classes, and other offerings.

When she came I gave her a tour of the place and visited with her. Jessica was excited about this baby and they had both already read a lot of information about natural birth and knew what they wanted. She gave me a copy of her birth plan which looked perfect. I wouldn’t add anything. Then she told me she was in training to be a doula. Oh, wow! This will be fun!

She had taken the DONA birth doula course already and sent for the certification package. ( At this point you have 2 years to meet all the requirements and submit your paperwork. She has attended a few births already and was gathering the rest of the information she would need. I invited Jessica to meet at my apartment for her next appointment and offered to lend her any books that I had ordered when I was being certified. Thus began our friendship. Since I didn’t need to educate her about labor or breastfeeding we used the times when we got together to look at birth videos, my own included. I had gone to The Farm in Tennessee to have my twins in 1982 with Ina May Gaskin and the Farm midwives when I had exhausted all the options to have a natural birth in Minnesota or Wisconsin. The birth was filmed and made into a teaching video called “Twin Vertex Birth”© Ina May Gaskin 1982. (See our story at this blog under the April stories listing, called Twin Birth on The Farm.)

I had several other teaching videos that Jessica had not seen, so we saw those together and talked about everything about birth and doulas and midwives and hospitals. This reminded me of the days two and a half decades before when I was expecting our 5th baby and I was starting to take classes which would eventually lead to my midwifery license. My mentor back then was my own midwife, Roberta. We were living in a log cabin at the time, our back-to-the-earth-simple-living experiment which was anything but simple. With 5 children and no electricity or running water (except if you counted my husband running the 50 gallon jugs up from the well at the pump house once a day), three still in diapers, and a ¼ mile dirt driveway which was impassible in the winter except by sled and also impossible the rest of the year after each rain which washed out the gullies further. But our 11 pound Hannah was born, though a whole hour before Roberta made it out to our rural route, parking on the road and hiking in the rest of the way. See “Wet Nurses and Other Alternatives to Bonding (and Free-Range Children)” at this blog also under the April listings.

It must have been past 5 a.m. several weeks later when Jim called to let me know they were in labor with regular contractions. I asked if I could speak to Jessica which would give me even more of a clue if this was early labor or the real thing by how well she could talk to me during a contraction. I encouraged her to labor at home a while longer if she was comfortable there. I called back around 6 a.m. not having heard again and spoke to Jim because Jessica could no longer speak through the contraction. I asked if they were thinking of heading to the hospital yet and he said they were still thinking about it. I offered to come to their house but they were doing OK so far on their own. When I called back again a little later I asked if they wanted to have this baby at home or in the hospital and that got them out the door in no time.

I was very excited for Jessica and had been looking forward to this birth. She was so down to earth, so well prepared, so healthy. Not all of the refugee and low income women we also serve are. I quickly dressed, checked my doula bag and called a taxi. I was at the hospital within 15 minutes. I asked at the desk if Jessica had shown up yet, and they assured me that they had not come in yet. A half an hour later, I checked at the desk again and they said she had still not arrived. Then they asked what her last name was, and they couldn’t find her in their system. I called Jim back and quickly realized I was at the wrong hospital! I had never done this before. I hadn’t opened her chart; I just assumed I knew which hospital it was. Apologizing profusely I hung up and called the cab company back. I couldn’t believe it. Was I getting senile? After this birth I put a pad of paper and a pen next to my alarm clock and I ask EVERY SINGLE TIME what hospital are we meeting at, even if I think I am sure I know, and write it down ... each time.

I arrived at the right hospital 25 minutes later, wearing my happy birthday tiara. At least we could laugh about it. She was still in the triage area of labor and delivery. There were no free rooms yet in the regular section. It was early, but there was really no room to move around at all and we couldn’t walk around the halls because there were families of all of the emergency room patients milling around. After monitoring the baby for a while the nurse said she would let us know when something opens up on the floor.

So we visited and breathed through the rushes which were steady but not unbearable. In Jessica’s own words, “We were finally moved to a labor and delivery room, though not in the midwife section, and they brought in a portable tub right away but had issues filling it, so ya’all were grabbing buckets of water from the sinks to fill it. I had to pee but just couldn’t and spent some time on the toilet whilst the tub was being filled… oh, and the popsicles, those were life-savers! Once filled I labored in the tub until I got too warm and stood in the tub and swayed and slow danced with Jim while you and my friend rubbed my back and fed me popsicles and water. Things were moving rather quickly. I came in at 6 and my waters broke – a water balloon between my legs!! and a couple of hours later I was 8 cm. Then things slowed down and I labored on all 4s in bed while ya’all reminded me to breathe and gave me my elixers -- H2O and popsicles. Once I felt the urge to push the midwife checked my cervix and I still had a lip on one side; later I learned that this is a sign of the malposition of baby’s head. I waited until I could push.”

Her midwife assured her that the baby sounded very good when she listened using a Doppler. Jessica explains, “Once pushing I didn’t feel like any progress was being made and asked if this was really possible.” It was hard to tell her she was doing everything right when she knew s/he wasn’t moving a whole lot.

“They made me change positions a few times, not delightful in high pushing mode, and finally ended on my back with my legs in the air and pulling on the sheet attached to the squatting bar. (Finally we could see a tiny circle of baby’s head.) Then the little guy came out after 2-plus hours of pushing. Bring on the waffles! This mama’s HUNGRY!”

She pushed for what seemed like forever and finally her baby boy was born, all 9 pounds and 6 ounces of him! And as he came out, out of the corner of my eye I saw a geyser of blood shoot straight up in the air. The midwife was at the bedside with Jim next to her. The nurse had not come back in yet. Somehow it registered in my mind that the cord must have broken at that moment, and in one move I spun around, grabbed a medium forceps clamp from behind us on the table and opening it up handed it to the midwife. We both saw the blood at the same time and both reacted immediately. She pinched the cord still at baby’s end with one hand and taking the forceps grabbed the placenta end of the cord as it disappeared back up into the birth canal. A bruise on the side of the baby’s head confirmed that he had been in an acyclic position, meaning his head was turned slightly sideways on the journey down to being born, which made it difficult to mold and difficult to descend properly. And now we knew his cord was short and just very grateful it didn’t break before he was out, which could have been catastrophic. It would have taken time to stretch so he could be born. It never ceases to amaze me how Nature accommodates such exceptions to the rules. The combination of all of these factors caused Jessica to sustain a 4th degree tear, which caused some complications later on though she was able to find help for it.

I saw Jessica and Taran (left) at our 10th year Birthday Party for Everyday Miracles last week. He is so amazingly strong, self-assured and inquisitive, a real ‘in arms’ baby. The difference is very obvious to me. (See at this blog the story under July listings called “The Ultimate Bonding Model.”) And now, having herself been on this bizarre, wonderful, outrageous, momentous journey of birth, I believe Jessica is truly a doula, able to put herself into another mother’s sandals or socks or bare feet at their birth. 

STAY TUNED... This and other stories will be appearing the book, Stone Age Babies in a Space Age World:§ Babies and Bonding in the 21st Century© or Call the Doula! a diary© both pending by Stephanie Sorensen

§This phrase was first coined by Dr. James McKenna, used here with permission and gratitude for his work. A world-renowned expert on infant sleep – in particular the practice of bed sharing, he is studying SIDS and co-sleeping at his mother-infant sleep lab at Notre Dame University. He is the author of “Sleeping With Baby: A Parent’s Guide to Co-sleeping,” 2007, Platypus Media, Washington, D.C.

“Around us, life bursts with miracles--a glass of water, a ray of sunshine, a leaf, a caterpillar, a flower, laughter, raindrops. If you live in awareness, it is easy to see miracles everywhere. Each human being is a multiplicity of miracles. Eyes that see thousands of colors, shapes, and forms; ears that hear a bee flying or a thunderclap; a brain that ponders a speck of dust as easily as the entire cosmos; a heart that beats in rhythm with the heartbeat of all beings. When we are tired and feel discouraged by life's daily struggles, we may not notice these miracles, but they are always there.” 

Wednesday, July 24, 2013

Rhoda’s Birth

I received Rhoda’s* referral for a doula late in her 37th week. She has gone to a few childbirth classes but is not super prepared for this birth. As we talk at our first meeting, I realize that she had other priorities. Addressing the abuse issues in her relationship was paramount. Getting the help she needed for her depression came next. At least she knew when to ask for help. We had work to do though to prepare for this baby, so I offered a plan: I could meet her at her prenatal appointments twice a week and spend time afterwards covering the childbirth education series and talking over any questions she might have. She was easy to talk with and very open about her situation. I knew we would work well together.

Her baby had been experiencing a concerning amount of tachycardia, or a racing heartbeat in her 7th month. She had been admitted to the hospital at that time so that they could figure out what might help her baby. When she was discharged, she was referred to a high risk clinic that would closely monitor her baby. There was some talk of inducing her at 38 or 39 weeks. By going to her prenatal appointments I was able to meet her OB, a wonderful woman, and ask my own questions about their birth plan. I was glad that I could tell her OB that I was looking forward to supporting her at this
birth and working together. I get a lot of mileage out of using the word ‘support’ with doctors. It tells them right away that I respect their role at the birth and that I do not have some natural-birth-campaign-only-or-else agenda. I think midwives and doulas may have gotten some bad press because of our push for natural birth over the past decades. Although I was a natural-birth-only licensed midwife for many years, had my own babies at home, my twins with Ina May Gaskin at The Farm** and my last two births three years apart were unassisted home births, though not by choice, my role as a doula changes all that. 

This lady has chosen this particular doctor and is at this particular place in her own journey. I certainly offer lots of information because I believe that if a woman doesn’t know what her choices are she simply doesn’t have any, but my style of doula-ing does not include insisting that she do a crash-course in NATURAL, though that would be my wish for all women. But the fact is that each new mom has a lifetime of conditioning that has brought her to TODAY and my job is not to fast-forward that to where I am right now. I cannot be the midwife and the doctor and the nurse at this birth.

My job as a doula is to mother the mother, to be the best doula I can be; to make her feel that she succeeded with the tools that she had come with and that she was a success. She should know she did a smashing job at this birth and that I fully trust she will be an equally awesome mother, too.

If I can do that, I have done my job well. I don’t want her to say, “I couldn’t have done it without you!” but rather, “We did it!”

With a high risk label already in place, our options might be a bit narrower than I would hope for, but this is what it is, and I will have to remold how I will do this and still have her think that her birth was an amazing, empowering experience. I can literally make or break it. That is a huge responsibility. I will be with her 200% more of the time than any other single caregiver during this birth. And that number goes up with each additional hour this labor takes. At some births I have been to, it is obvious that the nurse has sized me up and has probably concluded that we are a great pair – the mom and I – and that this will be an easy shift for her. We are often left alone for hours at a time, though I am careful to call the nurse the first time the mom wants to use the bathroom and needs to be unplugged from the monitor. At that point I ask permission to ‘unplug’ her for subsequent trips to the toilet. It is just one way that I can gain the nurse’s confidence and find a good working together with the birth team.

Rhoda warms up right away at our first meeting. I ask the clinic if I can use one of the rooms after her appointment to watch my Doula video with her. This way she doesn’t have to figure out how to add one more appointment to her busy schedule. She is still in therapy, goes to a support group and has a high risk pregnancy which entails extra OB visits, ultrasounds and monitoring. They are very accommodating and we agree to do this again with the breastfeeding videos at the next appointment at this clinic. I hope to bring up the subject of induction, too, before it is scheduled, so she knows how this might look and is at least prepared.

We meet again the following week and talk about her birth plan and what she expects from me as her doula. This gives me a chance to tune in to her expectations and we can talk about what the labor might look like and how we can work together to help her to be comfortable without medication, which is her wish for this birth. The nurse gives her all the information for the following Monday’s induction and answers all of her questions. We have our breastfeeding class, watching two of my favorite teaching videos, trying different positions with my baby doll Tofiq, and then pack up to wait for her taxi.

While we are waiting, she tells me that she doesn’t feel right about being induced. Her baby has looked great through all the tests that the clinic has ordered, so what would be wrong, she asks me, to wait another 5 days and see if she goes into labor naturally? I explain that she has a valid point, but that she will need to ask the OB and find out what her thinking is. The doctor may just assume that because this pregnancy is considered high risk that the baby would be better out and be treated if there is an issue, thus an induction is warranted. But does the doctor really have a valid reason for inducing at what might be 2 or even 3 weeks early? The last thing I want which would reflect badly on all the doulas in our group, is having her say her doula told her she might not have to be induced, so I am extremely careful how I word my response.
I explain that there are actually a few sides to this puzzle. 1. That they want to do everything possible to ensure that her baby is OK, so they turn to all the available technology (interventions) to assure the mom that they ‘are doing everything possible’. That also will hold up in court and protects the hospital from ‘not doing enough’ should a suit ever be filed, and 2. Their hospital is being watched just like every other hospital, to see if they are attempting to limit or lower their C-section rates and thus attract more clients (money is the motive here.) Are they perhaps thinking that her chances of having a C-section might go up with every week from now until her due date?  I don’t know that. I don’t know what the current statistics look like. But, 3., there may actually be data from studies that show that this kind of heart problem does indeed have a better outcome when we don’t wait till term. And this doctor hasn’t told us that --- yet. So I propose she ask and find out what is really going on here; can she ask for one more week to see if labor will start on its own?  I cannot, as a doula, encourage her to push for waiting for labor on its own, though I would have taken on that responsibility with my own births, but I cannot do that for someone else.

I may have the experience and knowledge from my years working as a midwife, but the doctor doesn’t know that, and this is now not in my scope of practice as a doula. Besides, this hospital does keep abreast of the very latest research and may have a very good reason based on “Best Practice” that I would not have even heard about yet. She is going to call me back tonight. I am surprised and glad that she has come up with questions on her own. I somehow imagined she was in that school of thought that dictates, “the doctors know best, just do whatever they say.” Again all I can tell her is, “Welcome to parenthood, my dear. This is the beginning of many tests of your strength and courage.” I assure her that I think she is going to make a great mom!

 She does have this conversation with her doctor and feels that they truly are doing what is in her baby’s best interest. I assure her in our phone conversation that we all, as parents, doubt after the fact if we have made
the right choices, but that this is the new territory we find ourselves in. We have to make choices that are best for us. Sure, we will make mistakes, even making poor choices that we will learn later could have resulted in different outcomes, but we have to work with what we know now, today. Yes, we’ll make mistakes, but I believe even our kids will know we did our best, always, for them.

So, we meet at the hospital on D day. We go over her options for pain meds and some of her wishes. She doesn’t want to be asked what her pain level is repeatedly. She has done her homework and knows she can ask if she wants something for pain. She would like to try the tub, birth ball and different positions first. She definitely does not want male providers during this birth if that is at all possible and no extra interns or students milling about; Crowds of people is absolutely something she doesn’t feel comfortable having to deal with.

It is Sunday evening and the plan is to use a prostaglandin cervical ‘ripener’ called Cervidil or dinoprostone  which is inserted into the cervix, sits there for the next 12 hours while you sleep, hopefully, and prepares the uterus for further induction in the morning. Occasionally the Cervadil alone will initiate labor but we’ll have to wait and see how it goes. I had encouraged Rhoda to eat a good supper before coming in because I cautioned that she may not be able to eat much once in active labor. Each hospital I work in has a different protocol for this.

So her partner takes her out to supper and they arrive in a great mood, ready to welcome their baby into the world. I have brought two of my favorite movies which we settle down to watch together after the Cervidil is in place. She thought even inserting it would hurt and is relieved it doesn’t. I have a copy of Birth Story which also helps to set the mood in the room. A very ‘down-on-the-farm-feel’ – literally – of a DVD about Ina May Gaskin*** and The Farm midwives in Tennessee. This initiates several questions about the use of imagery during labor and we talk about several aspects of that after the video. Then we watch “Everybody Loves… Babies”**** which brings up lots of observations about parenting in other cultures and models of bonding. I especially like Babies because of my own research into bonding and maternal-infant attachment and point out during this film that the happiest babies are not the two babies depicted in the two First World countries (the U.S. and Japan) but rather the two babies in the more primitive cultures in Third World countries (Namibia and Mongolia.) (See stories at this blog under June and July listings: “Primitive Bonding” and “The Ultimate Bonding Model.”)

Three hours later Rhoda is ready to sleep. The nurse brings in some juice for her and a pile of bedding for her partner so he can fold out the lounge chair/cot next to the bed. I live very close to this hospital so I suggest I go home and sleep also, assuring them that I will return within 15 minutes should they want me to come back, otherwise I will be there when they talk with the doctors in the morning about the next plan for her. They agree and settle in for the night.

I don’t hear anything during the night so I return at 8 a.m. after the shift change would have happened. Both of them are still sound asleep when I show up.
They are up when the doctors come at 9. Her OB doctor checks her cervix which is now 3 cm. Great news! They suggest augmenting the labor with a small dose of Pitocin to encourage contractions that in turn will hopefully help her to fully dilate. The couple agrees to this and the nurse unplugs the monitors to let Rhoda shower and walk around for a while. Before the doctors leave I ask if she can eat until she is in active labor. They readily agree that is a good idea, so we order a big breakfast. She told me she wasn’t sure she could eat and was afraid that she would throw up later if she did, but I tell her that this could be an all-day or even an all-night process and that she will need the calories and sugars on board to do it. I also tell her that Ina May has been quoted as saying that you can even dilate 1 cm each time you throw up because your bottom can’t stay tensed when your throat and jaw are so relaxed. I tell her we are prepared if she does feel her breakfast coming back up and I show her the drawer by the bed stocked with Chux pads and the little throw up disposable ‘hats.’ I laugh and tell her we in the business are very used to all this and that after you are a mother it doesn’t bother you anymore, at least not as much as before.

I don a pair of gloves from the box on the wall by the door and pick up the room a bit. After a night of blood pressures, temperatures and the morning IV placement, the room is soon littered with little paper wrappers on the floor and a few other pieces of trash and laundry draped around. I open the curtains to a beautiful sunny morning. Her breakfast tray is delivered and Rhoda tucks in. I encourage her partner to get some breakfast down in the cafeteria. He hesitates until I assure him that he has plenty of time and won’t miss the birth if he is gone even an hour. (Little did we know that his son would not arrive until over 36 hours later!)

The nurse starts the Pitocin at the lowest possible dose. Baby’s fetal heart tones sound great on the monitors and Rhoda is quite rested and feeling well. The monitor picks up some contractions but not strong enough for Rhoda to feel yet. Throughout the morning the couple rests, walks, she sits on the birth ball and orders lunch at noon. The Pitocin is increased and by 2 p.m. we have rushes every 5 minutes and she has dilated to 4 centimeters. I ask the nurse for a dilation chart (below) and go over this with the
couple. We talk about imagining opening up and I tell them about the recent birth I was at and how well it worked then. (See the story at this blog “Rethinking Obstetrical Drapes at Birth” under the June stories listed on the side bar.)

By evening we are working together to breathe through the rushes. They are coming every 3 minutes and getting stronger. Before her doctor leaves at the end of her shift she checks Rhoda again. 4 cm. This is discouraging for Rhoda but I explain that induction is not the same as natural labor and often does take longer. I tell her that she is holding up well and her baby still sounds really good. There is no need to do anything differently and the doctors are not in any rush either. I explain that it is far better to go slowly because it gives the baby’s head plenty of time to mold and this slowly stretches the birth canal, rather than tearing from going too fast. By just reminding the couple that their birth is going really well, they can relax and try to rest another night. Again I go home to sleep. The phone doesn’t ring all night. By the time I return in the morning, the nurse is checking her once again. 4 ½ cm. They explain that they really don’t want to break her water until the baby is a little further down in her pelvis. It is still early. We take turns eating and walking with Rhoda. 

By noon the doctors – we have 2 now – come in and explain that although the baby sounds good, they don’t feel that the Pitocin is doing as much as they would like and also would like to see her dilating better. They suggest that she rest a while, offering some fentanyl to take the edge off the pain and give her a break since she didn’t sleep much during the night. Rhoda agrees and is sound asleep in no time. She is almost 6 cm. when she wakes up. Her water has broken on its own. But by evening, the doctors have once again gathered and come in to talk to the couple. First they explain that although the baby sounds good still, they are afraid that her uterus will become tired and if this goes on much longer may be more prone to hemorrhage after birth. They checked her when they first came in and her cervix is back down to 5 cm. and swollen. Even though the water bag is now out of the way, baby does not budge at all. It may be because the cervix/uterus is tired or that the baby is still so far up that the cervix doesn’t have the baby’s hard head to dilate against which you would expect it to be doing by now. They offer a Cesarean section finally, explaining that she could wait another two hours or 10 hours, but she may still end up with a C-section after all that. Rhoda and her partner ask for a couple of hours to think about this and the doctors leave. 

Rhoda tries to figure out what she is doing ‘wrong’ but I tell her she is not doing anything at all wrong. I explain that we don’t always have control over our births. I tell her that this is again one of those curves in the road of parenthood that we all have to pass through. She wants to know if she should try imagery, or walking more, or lunges, or “maybe we can just go home and come back next week?” I remind her that the water has broken and we can wait – that is certainly her choice – but we don’t need to worry about that for a little while yet. I offer to leave the room so they can talk but they both want me to stay.

It occurs to me that perhaps she is totally in the dark about what a C-section is or how it looks, so I ask them, do you want me to explain what happens at a C-section? They both nod yes. 

I tell them that the OR is not much bigger than this room they are in now, also with a warmer for the baby, and two NRP nurses waiting by it to help baby breathe if he needs it. I explain that only 1 in about 1,000 babies will actually need neonatal resuscitation and most just need suctioning and stimulation to get going. I explain that it will be bright and that she will get an epidural but is awake the whole time, which surprises her very much. She just assumed you are ‘knocked out’ and baby is forced out somehow. I tell her that her partner will be sitting by her head and hold her hand and I will be on that same side of a big sterile drape also and will tell her everything that is going on and what to expect. I describe the ‘bikini’ cut where the incision will be, low on her tummy in the fold of skin above the pubic bone. 

She will have 2 doctors, one on each side of her tummy, 2 anesthesiologists, several other nurses floating around the room, another one at the instrument table and possibly a resident doctor or two. (We actually manage to avoid having any men at this birth, which I had forgotten we had requested earlier. She would not have noticed by then, but I was touched that they had honored her wishes.) I tell her that it usually only takes about 15 minutes or less from when they start before they lift baby out and he goes right to the warmer. Often dad can go right over there with him and touch his baby and take pictures before bringing him over to mom. I explain that she can hold him and talk to him at this point if he is breathing well and doesn’t need any help. Then she is sewn up starting with the uterus, then the surrounding muscles and lastly the outer skin is stapled shut. She and baby will go to the recovery room
together, often being wheeled there in the same bed, with mom holding him. She will be there about 2 hours and then go to her room on the postpartum floor where dad can spend the night and their baby can room-in, (and she can finally eat and celebrate his birth!) She will be in the hospital 3 or 4 days and have time to rest and recuperate. I explain that it is a longer recovery than a vaginal birth but that she should ask her family and friends for help during the first 3 – 4 weeks. I realize that by de-mystifying the entire surgery, it becomes a choice that they are willing to make.

Her only question now is if she can perhaps meet the OB who will do the surgery first. She wants to be OK with whoever this person is. The nurse arranges for the doctor to come in and they 'click' immediately.

When it is over, Rhoda can’t believe how fast it went or that she is already holding her baby. She is a very petite Latina SeƱora, so I am not surprised that her hijo muy guapo (very handsome son) is just under 6 pounds. The moment the doctor lifted him up, head first, she said out loud, “Oh, so you were trying to come down forehead first!” It is called a brow presentation and this now explains why the cervix didn’t have anything hard to dilate against and also why he remained too far up in her pelvis. He wasn’t in a total face presentation, but it was obvious he was looking up, basically, at the start of his descent. His face and forehead were very swollen and the head in front had tried to mold, but the back of his head had not even begun to. Hmmmm. So now we have our answers about what was going on. I alway marvel at how Nature does and also does not do things according to any script.

The last time I saw anything like this was 30 years ago now, when I was called late one night to translate for the labor and delivery department of a big public hospital in St. Paul. They had a Hmong family whose first baby was presenting face first. The family did not like the idea of an operation at all. They had immigrated only a couple of years earlier from Laos and had their own set of beliefs surrounding birth and death and bad spirits that might enter a body once it is cut open. And here is a pregnant body, besides. No, they would not OK a C-section, which the doctors were recommending and hoped I would talk them into. The mother-in-law was pacing around the room when I arrived. I listenened for a minute and realized she was basically saying, “Let her die. No uah-pi (operation.) We will get him another wife (too-paw-nia chia.)"

Well, the first thing I did was to have Grandma removed. The poor girl was terrified that she was dying! And they were going to let her, too, or so she thought! I assured her that we have some options here and that she doesn’t have to worry. The dad was just as terrified as she was. I explained that the baby was coming down OK, though its face would look funny and swollen for a while but it should be fine after a few days. 

I told them that their baby was still OK and that they had 2 options: continue with a vaginal birth, though that might not be easy, or go with a C-section. I knew they couldn’t go against the elders’ wishes and had absolutely no recourse there, but I explained that they did have a say in our country and we would support them. They both said they wanted to try a vaginal birth, though the doctors had hoped I would simply talk them into surgery, but I couldn’t. I knew that the entire clan had been called together in a palaver and consulted already and their answer had been ‘no.’ I also didn’t believe that her life was in 
imminent danger so I didn’t go into my 

‘take charge’ mode and try to scare them further. I didn’t tell the doctors that I tried my best to talk them into a C-section but I simply said they are going for a vaginal birth and that they understand the implications. I told the couple that she won’t die from this, though she might have in the primitive conditions back in Laos in Southeast Asia. I tried to help them feel that the doctors really were on their side and wanted to help them. I don’t believe the doctors had ever said she could die if she didn’t have a C-section. They just strongly suggested that it was a better route and the grandmother took off from there. Of course they did have their baby shortly after that and it went quite well. I told the parents that I have never known of one that
didn’t come out.

But that was decades ago now, and this little guy had tried the same thing. I can’t help but wonder if this would not have shown up on a late ultrasound in Rhoda’s case, which she was having often anyway because of the tachycardia. It is also a bit curious that with all of the internal exams that someone didn’t pick up a different alignment of the baby’s head sutures, or even feel the nose. Anyway I am not the nurse here, so I can only wonder to myself.

I went back for a postpartum visit the next day and found Rhoda walking a bit stiffly around her room but ecstatic. She was just happy that her baby boy was here and that she felt as well as she did. It was definitely not as bad as she had imagined, having a C-section. I gave her a hug and told her how proud we all were of her. I reminded her that she had done the very best she could and was an amazing, strong lady. And then she said, “Well, we did it!” 

Yes, my dear, we did.

STAY TUNED... This and other stories will be appearing in Stone Age Babies in a Space Age World:§ Babies and Bonding in the 21st Century,© or Call the Doula! a diary,© both pending by Stephanie Sorensen   

*All names and characteristics have been changed to protect privacy.
**See Twin Birth on The Farm story at this blog under April listings
**** See

§This phrase was first coined by Dr. James McKenna, used here with permission and gratitude for his work. A world-renowned expert on infant sleep – in particular the practice of bed sharing, he is studying SIDS and co-sleeping at his mother-infant sleep lab at Notre Dame University. He is the author of “Sleeping With Baby: A Parent’s Guide to Co-sleeping,” 2007, Platypus Media, Washington, D.C.

“The source of love is deep in us and we can help others realize a lot of happiness. One word, one action, one thought can reduce another person’s suffering and bring that person joy.” ― Thich Nhat Hanh

Saturday, July 20, 2013

Call The Doula! a diary© ~ July 15th

This may very well be THE DAY! I have been waiting for Alegra* to call for I don’t know how many days now. I am very glad that her midwife isn’t anxious about her approaching week 41. I have seen far too many inductions this year, though there is very little evidence that we are preventing post-dates complications by doing so, and there is less proof that we aren’t actually introducing more possible side effects by inducing at what only might be post-dates baby. Unless a mom was charting basal temperatures and knew exactly the date of conception, the only other predictor would be artificial insemination or in vitro conception, we might very well actually be inducing a premature baby. Too many times I have seen induced babies who still have all the signs of prematurity: ears flat against their head, lots of the creamy vernix skin coating, etc. Truly post term infants have long finger nails and often peeling skin. The placenta may have areas or patches of calcification. We are still waiting for some direction, called “Best Practice” on this one: when, if ever, is it truly warranted to induce a late baby? Opinions still vary widely among obstetricians. I get the feeling that the whole topic is being revisited at this time, and it is certainly time to address this.

For ten days I have not ventured too far from home should THE CALL come, either before the guess date or like now, after. I have planned suppers around what my family could easily assemble should I be gone when they get home. I learned this one the hard way: When turkeys were super cheap after Thanksgiving last year I bought one, thawed it for 2 days in the ‘fridge and stuffed it with homemade dressing. I got it into the oven, set the timer and went to start a load of wash. One hour into baking the phone rings. Of course someone’s baby decided that Today would be a good day to be born. I turned off the oven, made room in the ‘fridge for the giant roaster and quickly scribbled directions how to continue cooking it once someone came home. Since then, I keep a steady supply of salads in the house, often homemade Tabouli, Cous Cous salad, a Freekah dish that can be eaten cold, hummus or pesto and washed raw veggies. Maybe we should write a cookbook of easy-to-store meals for doulas?

I check my doula bag for the umpteenth time: Back massage tools (2), olive oil, lavender and pine scents, my furry Push-me-pull-me,** a can of champagne to set in ice water for counter pressure for back labor (works really well and we can open it to celebrate later!), mint gum, tooth brush, tooth paste, snacks – for me: dates, raw almonds, apples, trail mix, honey sticks – for mom, her paper work and 2 pens, a sweater – hospitals can be really cold at night, my rubber kneeler from a discount garden store (for me to use by the tub or birth ball and for mom to use in the tub if she wants to stay on hands and knees for any length of time. I also carry a book – should she fall asleep for a time, my I.D. badge, a purse with money and I.D. and my “hospital shoes”. I don’t like the idea of street shoes bringing in all their germs so I change into my comfy canvas shoe/slippers. I try to have some handmade baby hats along too, since a group of grandmas are constantly donating them to our office. Nail clipper, battery-operated ‘candles,’ umbrella, phone and charger, socks, my headache medication. I also have a hair band-type party tiara that says ‘Happy Birthday’ in big pink letters. I often wear that into the hospital if I think we might need to lighten up the mood in the room. It works every time. I have been known to tell a partner, “I don’t need to wear this the whole time, but you do” and they usually take me quite seriously, too!

I get a call at 6 p.m., sure it is Alegra, but it isn’t. It is a desperate doula. Could I be with one of her ladies for a couple of hours until she gets out of her college English exam? Sure. No sweat. She is eternally grateful. I ask for her first born son as payment. Not really. A first time mom, nervous about not having any support, FOB (father of the baby) not really in the picture, as of yesterday at least. Mary Running Wolf is sleeping when I arrive. So are about 9 other bodies camped all over the floor, each rolled up in sheets or blankets. It looks like she does have support: sisters, brothers, girlfriends and girlfriends’ boyfriends are all sacked out. Mary is not yet in early labor but they are keeping her because of some concerns with her high blood pressure. They are talking about using Pitocin in the morning. When the nurse comes in to check her blood pressure and temp she wakes up and I introduce myself. I assure her I will stay until Julie, her doula can come. When the nurse leaves Mary tells me that the pile of blankets on the floor next to the bed is her partner and she wants him at the birth. The FOB will not be coming. I tell her that is fine and that she is doing really well. Contractions are weak but they may pick up. I tell her it is great if she can rest now. I get her some juice and a straw and encourage her to drink most of it. I pull a chair up to the bathroom door and open it just enough to read by the light. Less than two hours later Julie comes.

Another call comes just as I am opening the door to my apartment. I am hoping it might be Alegra. A mom who isn’t due for another month is asking what she should do: she has pelvic pain, a fever, chills and feels really crummy. I ask her to call her midwife and let me know if they want to see her at the hospital. It may be a urinary tract infection, but as a doula I am not about to diagnose what it might be. She calls back to tell me she is going to be seen in the emergency room and asks if I can come. She is a single mom. I tell her I will meet her there.

7:30 p.m. They are just hooking up the monitors and have her in the maternity triage area. A woman is screaming in the next room and nurses are running every which way. It looks like they aren’t going to get her up to Labor and Delivery in time. Our nurse’s pager goes off and she too leaves. Carmen and I visit until she comes back, but not before we hear a very healthy baby crying! The nurse explains that they will monitor Carmen for about half an hour and then call the doctor to come and assess what is going on. They draw some blood and have her give them a urine specimen. We haven’t had time to visit like this in two weeks, so it is nice to catch up. I just wish she was feeling better.

Everything comes back normal but there are indications that she is quite dehydrated. They suggest she stays long enough to have an IV and she agrees. She feels 100% better after that and promises to drink lots more water than she had been drinking. I am glad that it isn’t early labor. Her baby needs to gain more weight before she arrives. I wait for her taxi home and hug her goodbye when it comes.

Back home I climb into bed after checking that I have set a clean set of clothes on a chair should The Call come. Which it does at 12:15 a.m. At last! It is Alegra! Contractions are 5 minutes apart and she has called her midwife who agrees it is time to come in. I have not had a mom this prepared in a long time. She has done her homework too, even presenting me with her birth plan at our first appointment.

We are settled in a large room and the midwife meets us there. I suggest hanging out in the tub in the bathroom while the birth tub is set up and filled, which will take a while. The room doesn’t have a built-in tub but the midwife and nurse haul in a huge assemble-your-own-tub-kit which is rather nifty, with a liner which is disposable. I bring in my battery-operated ‘candles’ placing them around the edges of the tub, turn off the overhead light, get Alegra’s jug of juice and settle in for however long we’ll be here. Her partner, Fernando isn’t here yet. He will get off of work in an hour and Alegra has assured him she will wait at least that long.
After the tub is ready we move back into the room. Alegra is so relaxed that I am surprised when her midwife checks her and says she is already 8 centimeters. Fernando arrives and is excited as well. Alegra is very quiet at this point, slowly breathing and not answering his questions. After the contraction she tries to tell him that it is getting too intense to talk. He doesn’t exactly ‘get it’ and tries to bring up the subject of the baby’s name which they are still not in agreement with. He playful tries to smooth back some of her hair and she smacks him square in the chest. He gets the message this time. I suggest he takes my place by the edge of the pool and just holds her hands. We switch places and they get into an easy rhythm, breathing, resting, breathing, resting…. He moves over and Alegra grabs his belt with both hands. He tries to pry her fingers off the belt and hold her hands but she has decided that this is what she needs to do in this moment. His jeans are creeping earth-ward, but he is the only one at this point who is concerned.

I tell her how well she is doing, that it won’t get harder than this, that she is really doing great. All of a sudden, with the next rush I hear the Universal Grrrrrrrrr! Midwives and doulas the world over recognize this sound, at least wherever women are allowed to birth naturally, instinctually, and are not rushed into the second stage and pushing. I whisper, “uh huh” to confirm that this is it, that she is doing it right. After the next couple of rushes I think I see the head crowning, though with Alegra in a squatting position, I am not positive. I silently slide over and whisper to her midwife, “I think you want to be here.” She takes the cue as the baby’s head becomes visible and tells Alegra to pick up her baby. This moment is the most magical span of time in the entire cosmos; I watch in slow motion: Alegra reaches for her baby as the rest of him slides out, face down. She brings him out of the water and up to her chest, dripping water the only sound. I can tell Fernando is totally blown away by this. It is the most amazing thing happening in the whole world and we are allowed to witness it. Little Xavier starts crying on his own which wakes his daddy up, who starts crying, too. Alegra is still in shock. She says that she kept waiting for it to get worse, to hurt more. She was prepared for labor to be harder to navigate, but perhaps because she expected it to be harder, she was able to integrate each stage as well as she did. We congratulate her and help her to the bed when she is ready. We don’t have to do anything for Xavier. He is pink and breathing and thinking about rooting already, lifting his head to look around. She thanks the midwife and me, though I tell her simply it was she who did all the work. We didn’t do anything, really. I tell her she could write the book on how to birth babies.
Here is Alegra’s story of her birth. I love seeing it once again through a mother’s eyes:

“The story of Xavier’s birth began Saturday morning, September 1, two days after his due date of Thursday, August 30th. On Saturday morning at 5 a.m. I woke up with some spotting. Nothing big and nothing happened after that, except that I couldn’t really get back to sleep again. Mom and I went out shopping ALL afternoon. Around 3:45 p.m., I noticed that it seemed like I had some pressure that came and went, nothing serious. When we got home, it was Saturday night and dinner was spaghetti – our family Saturday night tradition. We must have gotten home a bit later, because we didn’t eat until almost 8 p.m. Around 9:25 I called the midwives through my nurse helpline to leave a message. After a midwife called me back, I called my doula, and told her what the midwife had said. I told her I’d take a bath and then let her know how I was doing. So I made a warm bath and hopped in, and it was so relaxing and wonderful, the contractions (which by now I had figured out that’s what they were, even though there still was no “whole-belly-squeeze”!) dissipated and I figured my labor was slowing down again. “It’ll be another day,” I thought.

“But, when I got out of the bath around 10:45 p.m., wham! The contractions started up again and coming quickly – every 3-4 minutes. Actually that was with the minute-long contractions, so it felt like every 2-3 minutes. After a while I called my doula and she said it sounded like it was about time that I went in and that she would meet me there on the maternity floor. By this time, though, I had to pause so frequently that it took us a while to get out of the house with my hospital bags. “What department?” the security guard asked. I would have laughed if I hadn’t been in the middle of a contraction. “Maternity!!” “Oh, do you want transportation?” (Did I look like I needed a bus? Then it registered…a wheel chair.) Of course I chose to walk, which took more time. We had to buzz in through the secured doors of the maternity unit, and as they slowly opened, I saw my doula at the end of the hall in front of the check-in desk, waiting for me. Relief! She had gotten there first because it took me so long to get out of the house and then through the hospital once the contractions were coming more frequently. Heather, my midwife checked my dilation and said, “Good news! You’re already at a 6." They filled a warm bathtub for me to sit in until the big water birth tub was ready. I kept waiting for Fernando to arrive, but he was at work and didn’t come until after 2 a.m. When he did, I relaxed more and with a couple of heaves, revisited my spaghetti dinner. Actually, even though things were getting more intense, I remember almost laughing that the first thing I do is practically vomit all over him. I said something like, “You came just at the right time!” but Stephanie was encouraging: “You know what Ina May says, ‘every time you throw up, you dilate another centimeter!’” And even though I hadn’t been nauseous, throwing up actually did feel a lot better. 

“Not long after Fernando arrived (later I learned it was between 2:30 and 3 a.m.) the birth tub was ready, and it was time to move in there. By then the midwife told me I was at 10 cm. but the water bag was still intact. She asked if she could break it. I said yes, and after that, the pressure got a lot stronger. The lights were still low, except for a light over the bed by the monitor where the nurse was charting. The best part was that I was so grateful for everyone’s help, yet even though I had no emotional energy to tell them, or even to say thank you, they were very present and continued pouring it out.

“After it seemed like the pushing contractions were slowing down, finally with a change of position, the intensity of the pressure got heavier and heavier. At some point I remember thinking, "THIS is why women ask for epidurals," but it was a passing thought, especially with Stephanie and Heather's encouragement. I didn't realize I was tensing up instead of relaxing. Then I started making real progress (or rather, the baby did) and with each contraction, I felt a strong and repeated urge to push. Along with the pushing, I was grunting from deep down, primal sounds. I had a fleeting thought – my vocal cords are gonna hurt (and later they did) – but in the moment I didn’t feel anything except the pressure down under. Then Heather reached down and said, “You can feel the baby’s head. Reach down and feel it.” And I did – it was unbelievable. It was at that point that labor actually began to feel like pain – I felt the “ring of fire” – the stretching around the baby’s head, and I started panicking and felt myself closing up and was afraid that his head was going to go back up inside. Stephanie and Heather kept pouring out encouraging words for me to relax and not panic. Later I realized it hurt so much at that very end because I had both first and second degree tears. But I also reflected on the fact that I didn’t register actual pain until the last 15 minutes or so. Everything before that was increasingly intense, but not painful.

“I felt so desperate and to the point of no return that I just pushed as hard as I could. I started to feel his head push past the intense pain, then on a second push, his body. Heather’s hands were there to help adjust his body as he came out, and then she held his head down in the water as he slid out. She kept him there for a second, then without thinking I reached down and drew him up out of the water and immediately he turned bright red and started screaming. His lungs were clearly working. I was in shock. I had expected to cry. Once again, I was surprised by my own reaction. I had no urge to cry at all. I just stared gaping at the screaming creature in my hands. Later I learned he got an Apgar score of 10 both at 1 and at 5 minutes. Yay for Xavier! 

“The nurses and Stephanie and maybe Fernando (I was so NOT focused on them at that moment) helped me out of the birthing tub onto the hospital bed, where the baby was still attached by the umbilical cord. I was holding my baby, they were holding me. We didn’t cut the cord for at least 10 minutes, and then Fernando cut the cord after it turned white (“like cutting chicken” the nurse said) and the nurse clamped it. The nurse and Stephanie encouraged me to place him on my chest and allow him to spontaneously breastfeed, which he did – from the middle of my chest he wiggled to the right spot and started to latch on. Amazing!

“Heather and Stephanie both examined the placenta and Heather explained what she was looking for – how to gauge its age, the attachment of the cord to the placenta, and how to know it was all there. She even remarked that it was asymmetrical and that the cord was bifurcated – meaning that it split at the base as it connected to the placenta. The fact that I remember that is incredible, since I had been up since 5 a.m. Saturday morning and it was by then at least 5 a.m. Sunday morning, but I was wide awake. Tired for sure, but on an adrenaline high. It was still dark outside and the room was peaceful.

“A little while after I was stitched up, Stephanie told me it was time for her to go. She had only been up all night. I was so grateful for her calming presence the entire time. My mom came back in from the waiting room, and she got to meet her grandson for the first time. I rested as they weighed and measured him, and my mom took the first pictures of him in my arms. Then a nurse came in and as the first rays of morning light came up, I signed my admittance papers. Heather was going off-shift, but I was so grateful to her, my doula, the nurse, and Fernando for an amazing birth experience. Most of all, I was so thankful that I had had a natural birth in which I was free to move about freely and comfortably. I loved the calming and warming feeling of the water. I am sure this helped me to not have pain and to really appreciate and embrace Xavier’s peaceful entrance into the world.”

Stephanie: two weeks later I got a call early one morning from Fernando. He wants to pick me up at noon to go to a Salvadorian restaurant. I have never had their food and I tell him I would be delighted. I don’t have any appointments and I am free, so I am ready at twelve sharp. Lunch was amazing, but it was just as much fun to see how big Xavier had grown. Alegra is also a pro at breastfeeding. Then Fernando’s ulterior motive is revealed: he wants my opinion whether I think she has enough milk and if their baby was growing fast enough. I assured him that she was doing better than 99% of the moms I see and that his baby is perfect. Their doctor had told them as much, but he just wanted another opinion and wanted to be sure. I told him that he was such a good daddy for being concerned, and that he should continue to have skin-to-skin time with his son.
I add Xavier's picture to my collection of baby photos when they send one. I now have one more baby. I stopped counting years ago after baby number 200. He is probably my first Salvadorian baby. There are Mexican babies, Hmong, Kenyan, Nigerian, a Native of the Cameroons (Cameroonian?), Vietnamese, Lao, Togolese, Native American, African American, Liberian, Cambodian and melting-pot American babies.
And I love each one. I worry about some. I pray for all of them. Each one has blessed me. Each a perfectly unique little soul.

"You are … assisting at someone else’s birth. Do good without show or fuss. Facilitate what is happening rather than what you think ought to be happening. If you must take the lead, lead so that the mother is helped, yet still free and in charge. When the baby is born, the mother will rightly say: 'We did it ourselves!'”  ~  From The Tao Te Ching

*all names and characteristics have been changed to protect privacy unless permission has been given to use the original names.
**See: under ‘baby’ and order through:

STAY TUNED... This and other stories will be appearing in the book, Stone Age Babies in a Space Age World:§ Babies and Bonding in the 21st Century,© or Call The Doula! ~ a diary©, both pending by Stephanie Sorensen

§This phrase was first coined by Dr. James McKenna, used here with permission and gratitude for his work. A world-renowned expert on infant sleep – in particular the practice of bed sharing, he is studying SIDS and co-sleeping at his mother-infant sleep lab at Notre Dame University. He is the author of “Sleeping With Baby: A Parent’s Guide to Co-sleeping,” 2007, Platypus Media, Washington, D.C.