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 Señora, 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 http://www.focusfeatures.com/babies

§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

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