Tuesday, July 2, 2013

Rethinking Obstetrical Drapes at Birth

Four births from the past year in particular stick out in my mind. All of the mothers had written a birth plan and educated themselves about natural birth. None were easy. Interventions were used at three of the four births. But what could I have done differently as a doula? The most interesting factor though, is the mothers’ perceptions. They were decidedly different. One felt utterly traumatized. One was deeply disappointed and felt she had ‘failed’, the third mother felt good about her choices and grateful her babies were doing so well. The last mother was happy it was over and did not feel any of the negative emotions the first two did. All were first babies. So what was the difference?

Hadassah’s* family are Orthodox Jews. She and her husband had long looked forward to having their first baby and absorbed all the information they could from the Internet, books, classes and friends. Her labor at a free-standing clinic went very well until her water broke around 7 centimeters. There was meconium. Lots of it. Her midwife was not comfortable continuing the birth there and advised a transfer to a nearby hospital. As her doula I went in the car with her, coaching her during the rushes, trying to bring some of the same calm working together to this unplanned situation. The clinic had worked with this hospital before and we felt very welcomed when we arrived. 

The staff got her into a room and assessed that she was indeed progressing nicely and because the baby’s heart tones still sounded good, the obstetrician suggested that going for a vaginal delivery still seemed fine with him.

I stayed by her side throughout the birth and she delivered a beautiful little girl later that evening. I was glad that she had not needed a C-section and that her baby did not have to go to the NICU nursery, but was doing well. So why has she felt that this birth was the most traumatic event of her life and needed to go through intense therapy for the past 8 months? In her words she felt “humiliated, vulnerable, exposed, degraded and in shock.” She felt the nurses didn’t respect her, chatting about insignificant things during her labor and that her midwife withdrew all of her support the moment they arrived at the hospital, after having built a relationship with her over the past 7 months, and that having a male obstetrician was an ‘unfeeling’ choice that the hospital dumped upon her.

Tessa is a yoga teacher. She ate extremely well, exercised daily, and seemed to have an amazing attitude toward natural birth. Her labor was long – two days of prodromal labor or early labor wore her out. Instead of sleeping when she could, she and her husband hiked the neighborhood the whole first night, trying to encourage the real thing. They checked into the clinic in the morning and had made little progress. At that point her midwife suggested they hire a doula to work with them at home until she was in active, effective labor. That is when I got called. I had not met this couple before but felt right at home when I met them at their house. I explained that it seemed that the contractions were petering out because like a car that won’t work unless it is re-fueled her body was telling her it needed rest and food. I suggested she rest, which she didn’t object to this time, while I cooked up a pile of whole grain pancakes and served them with yogurt and honey. She ate the entire plateful and then they both slept for 6 whole hours! A huge rush (contraction) woke her up. When they were 5 minutes apart we went back to the birth center. She labored in the tub for several more hours but seemed to have gotten stalled at 8 centimeters. Her midwife tried having her climb stairs, squat, walk, try lunges but nothing was helping her baby move down any further. By dark she was again exhausted and very discouraged. The last ultrasound she had suggested this baby was about 8 pounds, but she was six feet tall and seemed to have plenty of room.

The couple finally decided to transfer to the hospital. Tessa wanted something for pain at this point and asked me to come with them. The baby sounded great and the OB felt that she just needed more time. She opted for an epidural which gave her much-welcomed relief and as she was able to relax finally became fully dilated. She started pushing but after an hour, the baby still felt very high up in the birth canal. The doctor tried massaging the posterior wall internally hoping to stretch it father and help baby along. It seemed to help, so for the next hour he kept his hands where he could direct her pushing from inside. She pushed until the head was finally crowning but the doctor explained that what we were seeing was caput, or the baby’s swollen scalp which had also stretched, but that the bones of the baby’s head were still molding and had a ways to go yet. I had never seen someone push so hard for so long. I wondered what we could have done differently or better. I would have my answers when he was finally born: he weighed in at 11 pounds 2 ounces, almost 3 pounds bigger than anyone guessed. He also had the shortest umbilical cord I had ever seen. It took that long to stretch without detaching from the placenta which would have proven fatal for this baby. So Nature did know that what was needed was time, and more than most births. Much more. Tessa felt afterwards that she had not prepared herself fully for the rigors of childbirth. She felt keenly disappointed  and robbed of what should have been an ecstatic experience. She felt cheated against her will. She regretted having ‘failed’ by asking for the epidural. She asked me if she would regret these choices for the rest of her life. It should have been different, i.e., better than this. Could she have somehow been stronger?

Amber couldn’t believe it when the technician at her first ultrasound congratulated her for having twins but the euphoria completely wore off when, toward the end of the pregnancy she was put on bed rest for 3 of the longest weeks of her life. She read books, talked on the phone for hours, watched TV, ate and slept and did it over and over until she went into labor one morning at almost 37 weeks. I met her at the hospital within an hour.

We spent the day walking, resting, sitting on a birth ball, in the tub and munching on snacks. The hospital staff was amazingly open to intermittent rather than continuous monitoring and allowed her to eat and drink. They left us by ourselves for most of the day. Things were going really well until about 7 centimeters when Baby B’s heart tones became a concern. Twins are labeled A and B, with A engaged or lower in the pelvis and most likely to be born first. Surprisingly, the obstetrician didn’t rush to intervene but waited and watched for enough of a change that he could be reassured. Other factors, none critical by themselves alone but enough in combination to raise concerns including the fact that all of a sudden the contractions were spacing themselves out from 5 minutes apart to finally 10 or 15 minutes apart and Amber’s blood pressure slowly rising had the doctor call together the birth team with the parents to rethink their plan of action.

Although Amber had written a birth plan and had educated herself extensively about natural birth and the possible interventions, she was amazingly relaxed about having to switch gears at this point in time. She asked me what I thought and if I had any suggestions. I told her once again (this had come up several times in our prenatal meetings) that I will not make any decisions for them, but I can give information to help them figure out what would be best for their family. I told her that of course she could again take a wait-and-see approach and ask for more time and see where they get, or go with a Cesarean section right now, which is what they opted for. Dad and I were given “bunny suits” to put on over our clothes along with sterile hats, masks and booties to cover our shoes. By the time we were gowned up Amber had been given an epidural and we joined her in the operating room. I stayed by her head where I could narrate what was happening step by step. Her partner held her hand and sat in his assigned place trying to take it all in. Within 10 minutes I was explaining that she would feel quite a bit of pressure or pushing and tugging and that the first baby would soon be out. Within another minute Baby A was crying and being rubbed down on a nearby warmer. 

Within 3 minutes Baby B was also out and on his way to a 2nd warmer. Two sets of nurses trained in neonatal resuscitation were standing by ready to assist either or both babies to breathe if needed, but they were both doing really well on their own and were given excellent Apgar scores. All of a sudden two very healthy babies were both crying while they were being wrapped up to make the trip over to meet their mom. 

Dad was given a baby on each arm to hold where Amber could see and touch them. I squeezed into the remaining few inches left at the head of the table and kissing her told her how very proud we all were of her and that she had really done it! It was beautiful watching them: this little family of two suddenly doubled and there are 4 people! They asked me to take pictures so I tried to get lots of different angles without stepping on some nurse’s toes or bumping into one of the anesthesiologists. Finally we were all transferred to the recovery room, babies and all, where Amber could nurse them. Vincent and Victor were safely here!

Although she had a long recovery ahead of her, Amber was happy and grateful for the way things went with their birth. She told me “it was what it was” and everyone was here and healthy. It was amazing in her mind, that she could experience labor first and that she had done everything she could have done. As a doula, my job is to affirm that and honor her journey.

Birth #4. I love working with the immigrant community in Minneapolis. There are over 70,000 recent African refugees living in Minnesota alone. There are also almost as many Hmong in the Twin Cities who began immigrating after the Vietnam War. So when I got the referral for a new first-time mom from Ethiopia, I was excited.

I met with Eleni every week leading up to her birth. We covered all of the material in the childbirth education series during our prenatal visits that we squeezed in between her busy work and school schedule. She couldn’t go to a regular class offered at one of the local hospitals because she had to take the bus to get there and did not want to do that at night. Her husband worked the night shift so he couldn't accompany her. So we met and watched the teaching videos and addressed all of her questions during our visits together.

She had a difficult pregnancy, complicated by an infection contracted before she arrived in the U.S. and then another rare event affecting her fluid retention. Her OB carefully monitored both her health and the baby’s during this pregnancy and felt that a natural birth was still possible as we neared her 40th week. Both conditions would be treated after she gave birth but could only be observed and followed until then. She was still not showing any signs of going into labor at 41 weeks but everything looked ok, though her OB was guarded about waiting much longer. A few days later Eleni called me from her OB appointment that she was being advised to go in that same day and have her labor induced. We would meet at the hospital later that afternoon.
When I arrived the family was still waiting for an Amharic translator. The OB doctor wanted to explain their options for starting labor and wanted to be sure the couple understood everything. That done, we settled in for a long day. The prostaglandin that they used worked quite well to ripen her cervix and within two hours we had contractions, light ones but increasing and she began dilating. We kept waiting for active labor to begin – the point where you are 4 centimeters and have good, regular contractions – but instead of the ideal 1 centimeter per hour, we were going along at about 1 centimeter per every 3 or 4 hours. Eleni’s OB seemed unconcerned and told us that as long as this baby sounds good, and she did, that we didn’t need to rush things at all. This was a far cry from the ‘old days’ that I remember where you simply kept adding intervention after intervention to make it ‘work’ within some magic time frame no matter what. So she ate and drank, rested, sat on a birth ball, walked the halls and rested some more over the next 15 hours. At one point the doctors suggested trying Pitocin if things slowed down any more, but put off that idea for a few more hours. By morning, they asked if the couple was OK with that or what they would like to do. We talked about it and they asked if rather she could get something to help her rest for a while and see if the rushes would pick up on their own if she was less exhausted. We had discussed some of these options during our prenatal appointments and as Eleni was still wishing for this to be as natural as possible, the doctor agreed. We turned off the lights, closed the door and Mom, Dad and I – draped over the lounge chairs in the room – all got in a 2 – 3 hour nap which felt great.

We woke up when her water broke toward the morning of the 2nd day. It was clear and her baby girl still had an amazingly good heart rate when they checked her. Still at a rate of about 1 centimeter every 3 or 4 hours, she slowly progressed. It was enough progress, and not regression that the doctors – we now had 3 women doctors checking in with us – didn’t feel that anything had to be done, but said that they could offer a few ideas if Eleni was interested in speeding things up. I assured her that this was up to her but that her baby sounded very good. She continued to eat and rested when she got tired of walking or being up on the birth ball. She spent the next few hours in the dimly lit tub room, dozing as I slowly dribbled a steady trickle of warm water over her belly. We were at 5 centimeters, still considered progress.

When the rushes started getting stronger, Eleni told me she was scared. She didn’t know what to do next. She didn’t know if she would be too exhausted to push later. She didn’t know how much more she could stand. I explained (again) that this is the longest and the hardest part of labor, that going into transition is the end of this stage and that she was doing wonderfully. I told her that baby still sounded really great and that we would help her with each rush as they came. I reminded her that she only had to do one rush at a time. Not all at once. 

She closed her eyes and lay back down in the water. I was calculating in my head that at this rate we could be doing this for 8 or 9 more hours….  

Then it occurred to me what Ina May said in the film I had just seen called Birth Story, where she was watching a first-time mother opening until she was just huge and later when she asked the mother how she did that, she said simply that that was what Ina May had told her she would have to do when the time came. We could use imagery, too. I had with all of my own births, but had not really ever talked someone else through it, however I figured we should try it now. So I said, “Sweetheart, look up at the ceiling… see that big black circle? (The exam lamp). That is how big you need to be. You will open like a flower, petal by petal. You won’t break. You have lots of room and your baby isn’t huge. She is probably 6 or 7 pounds, just right for you.
Your body knew exactly how big to make her and your body knows just how to get her out. You don’t have to really DO anything. Just let the rushes open you up that big. You won’t break. We were made to do this….” And so it went for the next ½ hour until suddenly we had some really big rushes and Eleni said she had to poop, like, RIGHT NOW! I told the nurse that she hadn’t been to the toilet in over an hour so we got there and convinced her she shouldn’t try to push yet. Next she got up on the bed and the nurse checked her. 9 ½ centimeters! 

Boy, had I learned something!

I want to add here that this family is Muslim. We had written in her birth plan that she wanted only women at her birth, did not want any male residents or students observing and that her husband might not stay for the actual birth, which was part of their tradition. Knowing this, I made sure to alert him every time a nurse wanted to do an exam and gave him the chance to leave the room if he wanted to. Even with only women present, she kept her head scarf on the whole time. I also made sure that she was covered with a sheet whenever she changed positions and had a robe besides her night gown whenever she was not in bed. I was careful about keeping the door curtain pulled so she couldn’t be seen from the hall. During exams I made it my job to hold up the sheet enough to give the doctor or nurse access, but shielding her from the other women in the room. I had incorporated this into my doula job description early on when I began working with Somali women. (See March story at this blog: Welcome to the Twin Cities of St. Paul and Mogadishu!)
Finally she could push! Her two sisters helped with her legs while I wiped her face and neck and helped her breathe. Her husband had stayed but preferred to sit close by and pray, too overwhelmed by it all to trust himself to be any closer. I gave him an update every few minutes as the baby’s head and thick curly black hair came into view. I couldn’t see what was going on down below. It was my job to be where I could encourage her and calmly whisper in her ear, “You’re doing it, honey! You are so strong! That’s it! Ok rest now…. That’s it. OK, another deep breath… slowly... you’re doing it!”

All of a sudden the three doctors moved into high gear. I wasn’t sure what happened, but I knew something wasn’t right. I stayed where I knew I was needed as I watched one of the doctors get up onto the bed and begin fundal compressions. She was too short to work effectively by the side of the bed which had been raised for the delivery. 'Oh my God!' I thought; 'shoulder dystocia:' every midwife or doctor’s nightmare. They had 3 or at most 4 minutes to get this baby out. If they wait too long, the oxygen deprivation could cause Cerebral Palsy or permanent brain damage (See diagram below.)

I knew the doctors and nurses had the drill down so that they could do this in their sleep, and I knew Eleni was still holding her two sisters’ hands so I turned to her husband whom I knew wouldn’t have a clue what was going on. He looked terrified. No wonder: it looked like the doctors were giving his wife CPR. I took his hand and told him that the baby was stuck and that they were working to get her out, that they were trained to do this. And within 3 minutes, they were carrying baby to the warmer where the NRP team was waiting. I assured Dad that his baby was out and was getting the help she needed. Eleni had her eyes closed but was still holding her sisters’ hands. Within a few more minutes we could hear baby cry, at first little whimpers and then really loudly. I told Dad to go over and see his baby and be sure and bring the camera. For the family’s sake, I could go back into an ‘all is fine’ voice and reassure them. I tried to sound like ‘this is all perfectly routine here’ though I knew we had just been in a very scary place. They would never perhaps fully understand the gravity of the situation.

Eleni tore quite a bit, possibly from the attempts to pull the baby’s shoulder out and needed the repair done in the OR (operating room) afterwards. She was happy that it was over and that her beautiful big girl – 8 pounds! – was now snuggling on her chest where they could get to know one another. We gave baby to her daddy and I accompanied Eleni down to have the repair done. She was positioned on the table and offered a shot for pain which she agreed to as they hoisted her legs up into ‘candy cane bars’ for the best position for the repair. I overheard that they were waiting for the OB to come to do the repair. I asked if it was a ‘he’ OB or a ‘she’ OB. They said ‘he’ just as he walked in, so I explained that it would be nice if she was draped except for the area he had to work on. Without waiting a moment they all flew into action looking for the sterile kit that actually has leg covers and other drapes. They had never used them but didn’t hesitate for a second when I asked. She was awake during the 2 hour procedure. I stayed by the head of the table and told her how well she had done and how good her baby looked. I told her that she would look really nice when the swelling went down and they had fixed the tear. I walked around to watch with the other 3 women doctors as the last stitches were put in and returned to the head of the table where I whispered in her ear, “You look beautiful down there. He did a really good job!”

When we returned to the room Abrihet’s daddy was holding her, still looking completely bewildered. It was a lot to take in. He was happy, but just his look of utter wonder stayed with him all evening. I told him he should be very proud of his amazing, brave wife! The sisters called relatives who fixed food and brought it in for all of us to eat. At one point while we were all eating fragrant rice and they were feeding Eleni and giving her the proscribed spiced hot milk for all new mothers from Ethiopia while she was holding her baby, Dad looked over at me and asked, “What was all that about, anyway?” So I explained what had gone on, how when we see a baby’s shoulders get stuck, we know we don’t have much time to get her out because if she doesn’t get air in time, she could have brain damage. That is why they had to hurry and try different things to get her out. I told them that I had learned to do it exactly that way too, in midwifery school years earlier and that we are taught about situations like that.** I explained that I am glad they acted so quickly. I told him they would ex-ray the baby later because she may have fractured her clavicle bone (there was a strong suspicion because she wasn’t lifting her right arm) but if that is the case, babies heal very quickly and they will show him how to care for it before they go home.

Eleni was happy that she had not had a C-section. She was grateful to the doctors whom she kept thanking whenever they came in her room. She was in love with her baby right away and was still holding her two days later when I did a home visit.

"I've learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel."  ~ Maya Angelou

I am wondering if by respecting her wish for modesty her requirement for satisfaction with the birth was met. I seriously wonder too, if we had made a concerted effort to use drapes throughout labor and birth that Hadassah ’s and Tessa’s feelings of “being exposed” and “humiliated” might have changed, or at least after we had transported to the hospital in both cases. As we are beginning to see more research into what constitutes traumatic birth and even the symptoms of PTSD after some births, I wonder if we could not somehow think more about honoring or respecting mothers’ bodies differently. Of course many women are fine giving birth completely au natural (myself included, though I was in my own home each time) but in the first two cases described here, I would like to think it might have made a difference. (See the work that Penny Simkin is spearheading with PATTCh: prevention and treatment of traumatic childbirth: www. pattch.org)
(Victor and Vincent, above... or it could be Vincent and Victor!?)

**I have since called the doctors back, first thanking them for all they did and allowing me to be part of the birth team, and then offering to facilitate a mini in-service sharing the new movie Birth Story which I have a copy of, having contributed to the film -- they used footage from our twin birth with Ina May Gaskin in 1982 -- in which the Gaskin maneuver is used for an actual shoulder dystocia that was filmed at The Farm. Their response was very amazing and they are very interested. We are scheduling this event at the present time. (See the story: "Twin Birth on The Farm" at this blog under March postings.)

*all names and characteristics have been changed unless permission 
was expressly given by the families.

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

§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.

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