Sunday, March 23, 2014

Welcome to the World of Doula!

How would I describe them? Not shiftless, just idealists. Anarchist perhaps. Communists? No, but maybe Socialists. Hippies … I think that could fit too. They were living in a community of sorts; four houses on one street, vegetable gardens and chicken coops in between the houses. Yes, in the city. Faded jeans and unbleached diapers always hung on the lines above the chicken coops. There were usually kids playing some game of tag, running past you at the speed of lightning.
We had gone to a few of their neighborhood cookouts and a potluck wedding once. The square block of bicycle parts that had formerly littered the drive were miraculously all put away before the wedding. I can’t crack on that wedding. It sure beats taking out a loan just to get married in a dress you’ll only wear once (like I did) and to pay for a caterer when you could have cooked much tastier food yourselves. There is something to be said for living simply: no debt, no car, no insurance, no phone bills; just hang out and find a job you like. Go dumpster diving behind all the co-ops and bakeries and grocery chains and harvest all you need for a whole week’s worth of food. Sure, the luxuries of life will be gone, but you’ll find treasures hidden in Nature and other people instead. They had a point there.

But when it came to babies, I would have drawn the line. Sure, I had mine at home, some with midwives and 2 in such a hurry three years apart that no one made it to those. But if something had gone wrong we would not have hesitated to transfer to a hospital. That’s what they are there for. And there are countries all over the world where babies and mothers die every day because they don’t have the facilities that we have. But to boycott all hospitals under all circumstances because they are part of a materialistic, consumer-based conglomerate and perpetuate our capitalistic policies, and they only enable the rich and don’t serve the poor equally, does not mean we should never, in any unforeseen eventuality set foot inside their marble halls. Except this is exactly what they had decided: to do without ‘the system’ entirely and live in the fringes at the edge of the rest of the population. So when Juliette got pregnant, they looked for specifically and found an unlicensed home birth midwife who shared their world view.

Then they asked me to be their doula. I hesitated. Did they have a plan B should they need to employ one? No. Did the midwife have any backup? No. If she needed it what would she do? “Nothing” was the answer. They were on their own there. They could show up at a hospital, according to her, but she would not come along. Oh boy. I wasn’t sure. It grew on me slowly. They rented a birthing tub for their tiny room. They ate well enough and she was gaining steadily. Then came the last straw: she told me that had high blood pressure and a congenital problem with a kidney. Holy @$#&!
I told them that I couldn’t be their doula unless they had a doctor backing them up. And she would have to do that before her 8th month. If I was going to be their doula and be her primary care provider at her home until we called her midwife, I would need to know that she had been screened and approved for a home birth. And my scope of practice as a doula would not have me doing blood pressure or sugar checks anyway. Then we would have to have a plan B, but the doctor who already knows her would be meeting us at the hospital, should we need to transfer.

I didn’t hear from them for over a week. At this point it was clear that they were obviously battling between themselves over priorities versus idealism. She understood my concern. He did not; he dug in his heels and did not want to budge. This one definitely threw a wrench between them. Their relationship had not been a committed-until-death-do-us-part arrangement and I didn’t want it to get to the point where she could actually be at risk for leaving us all together, as in some fatal complication, which was not entirely far-fetched on my part, knowing of some of the medical issues. I know I didn’t trust enough that Nature knew how to birth this baby, and I had perhaps lost sight of the midwifery model of care favoring instead our allopathic brand, but….

Juliette called me the following week. She had been to a regular ‘establishment’ doctor whom she said cleared her for a home birth. Great! Her blood pressure and sugars were within normal range, so they were delighted with this and wanted to proceed with their original plan, but then as another week unfolded things changed. Drastically. She was sick and not having much luck getting back on track. She went back to the doctor and as she edged nearer her 8th month, was put on several medications and a restricted diet in the hope of stabilizing both the kidney function and blood pressure. In spite of the ominous recent chain of events, her midwife told them it was still the better choice to have their baby at home. Really?

They had scraped together the midwife’s fee by begging and borrowing from family and friends and selling an old car he had fixed up. She was officially hired. I, on the other hand knew that they didn’t have any savings and offered to barter. Pierre, an accomplished carpenter could suggest something he could build for us in exchange for my doula services. Everyone was happy.
About 6 weeks before her guess or due date, Juliette called me saying she was having horrible head aches and feeling really crummy. I insisted she return to the doctor and get it checked out before it got any worse. It could have come from stress, she admitted. Her partner was nowhere ready to have this baby. He wouldn’t pack up his tools or the mountains of junk that covered the floor of their tiny room in the house. The birthing tub had to somehow fit in there. And she had expressed the wish that they move their mattress onto the floor in the main room from its place in the loft where it stood on a platform up on stilts. It was stuffy in there and too high to climb up and down with a baby. But he was not moving to help with any of this. Juliette blamed herself for being so picky and cranky, but they weren’t really as together as she had hoped they would be, especially with a baby on the way. I could only encourage her to keep the lines of communication open with him and that in the end she had to do what was right for her and her little one, even if he didn’t agree.

The report from the doctor was not good. He strongly recommended that she check into the hospital that same day and be induced. Her overall numbers were not good. Her kidneys were being taxed and the blood pressure was too high. He felt that her health could still recover after the delivery, though she was getting into hot water already and waiting would not guarantee that she might not come out of this without some permanent damage, and the baby’s health would only be compromised and at risk if she didn’t deliver soon with these new developments.

Negotiations with their midwife went back and forth all that day. She was willing to help them should they choose to stay at home, but I made it very clear that I could no longer be part of it then, and she countered that her job description didn’t include being with them throughout the whole labor, that was why she had recommended they find a doula, even though they had paid her several thousand dollars. I told them that the hospitals are there precisely for these kinds of situations and that I felt the doctor was on their side, committed to having a healthy baby and a healthy mother in the end. The battle had begun.

So the cards were blatantly stacked against them. Her health might not recover if she didn’t deliver the baby soon and may even become permanently damaged, putting her at grave risk. I pointed out that her baby needed a mom and that although we would like to have control over our health and our births this is not always the case. Welcome to parenthood. I could not tell her what to do, but I could encourage her to think on her own, without Pierre going on and on about corporate greed and disregard for the poor and multi-billion dollar facilities. He just didn’t get it that her life was creeping closer and closer to a point of no return at this rate, her numbers were now that bad. I had never had a mother this sick in my 30 years of midwifery practice, partly because high risk births were screened out through my protocols and I would have been required to transfer care weeks ago in her case.
I told them to call me if I could do anything for them and let go. I had not been this frustrated in a very long time. I said a prayer and made supper. Later that evening she called to tell me that she had decided to go to the hospital and asked if I would be able to meet them there. I said I would be glad to.
I explained what induction meant and how that might be attempted 5 weeks before a due date. She had written a birth plan and we had talked about the numerous options that she had for a home birth, but then tailored that for a hospital birth. Now we had to add induction and what she could agree with and what she did not want to try. Her choice was to have her baby as naturally as possible with as little intervention as possible. I outlined the various options the doctor has for induction, explaining that some were more invasive than other interventions and that she would have time to ask questions and could ask for privacy to decide what she wanted to do. Once she was settled in her room the doctor suggested a plan to start up labor by using a ripening agent placed at the cervix that would help get things started. Then they could start a small amount of Pitocin by morning and get her into active labor. Sometimes these will work quite well but occasionally they don’t do much at all and then the doctor will suggest the next trick up his or her sleeve. So the couple asked for some time to discuss this privately. We all left and I went down to the coffee shop to get a drink.

They called me on my cell phone shortly after that to tell me that they had called their midwife for advice and she had warned them about what not to let the hospital do to her under any circumstance and suggested some alternatives to try. I did not realize she was still in the picture and found this rather bold for her to be making decisions from some undisclosed location. So the night started off with a bang. They agreed instead to a non-medicated approach and opted for a balloon catheter to be placed that would stretch the cervix open and hopefully trigger labor on its own.
By morning it had succeeded in getting the cervix to dilate slightly but not appreciably. The next suggestion was to try Pitocin and then perhaps breaking her water if the baby’s head came down further. Again the couple asked us to leave and talked it over, and as I suspected, again called the midwife who told them not to let them break the water under any circumstance. I had never seen anything like this. I did not understand their trust or devotion toward this woman. I was mystified by it. I knew I was considered a close friend, but somehow by my being a licensed midwife and certified doula, I had gone over somehow to the ‘other side’ and was deemed too medical or too swayed by ‘the system’ to be consulted on how to stay on the natural side of things, is all I can guess.

The nurses soon got the hang of how to approach this couple. Each step would require consultation, then consideration in private, then double checking what I thought (but only after the other midwife was called) and then the nurses and/or doctor could come back in and negotiations would resume. I was beginning to feel like an international conflict-mediation envoy deliberating the politics of civil unrest. Many of the suggestions only met with rejection as being too invasive or they simply felt that things were being unjustly and routinely rushed and asked for a few more hours of walking or sitting on the birth ball to let things work. I took to listing options for them from least to most invasive, knowing they would veto any and all suggestions unless the guru midwife approved of it. The nurses started asking me to ask them thus and such – hoping I had more say because they realized they did not have in fact any at all. My only objection to their midwife was that she was simply calling the shots in a realm that I felt was now outside of her sphere of skill or experience. 

I do not go to a birth at home or in a hospital ready to do battle. I sincerely feel honored to be welcomed onto a birth team and readily defer first to Mom and her wishes and then follow her midwife’s lead. But this tug-of-war went on all night and all the next day. By evening I was called out to the nurses’ station and given an overview of the bigger picture. Baby was still doing remarkably well. Mom was OK, blood pressure and other numbers not off the charts yet. But it was time for baby to be born. I asked what options they would propose next and breaking her water was the least ‘medical’ in their eyes and might speed labor up appreciably. I went back in and sat down, slowly rubbing her feet as I balanced on a birth ball at the foot of her bed. They were not agreed between themselves what to do next. I told them that they were doing great, that baby was sounding really good and that she was actually making progress, which is not the same at an induction as it is in a term birth. I proposed I go home and sleep and that they try to rest, even if it was only dozing between the rushes or contractions. She was able to eat and drink and was doing OK there. She had refused all IVs and meds up until this point. I knew they would continue to call their midwife whether I was there or not, and was frankly at my wits’ end at 48 hours. I hugged them each good bye, assuring them I would be back within 15 minutes if they wanted me.

I walked the short 6 blocks home. I was so tired and drained that I just showered and cried until I got into bed. I did not ‘get’ this. 
I had a call a week earlier from a birthing clinic asking if I could consult on a breastfeeding problem they were seeing. The couple was from the same tribe as my laboring mom and dad were. They were vegans. Fine. I was too during my twin’s pregnancy and birth and since then. That was not the problem. The issue was that he thought she should be able to skip drinking altogether until they could find a 100% pure reverse-osmosis water source and that they could get along just fine with just raw foods they would ‘harvest’ from around the city. It quickly became obvious that he was dictating or controlling everything she put into her mouth! It turned out she had not eaten that day and possibly the day before. She was very thin and very pale, had not taken vitamins and as soon as I started prying a little further, she simply looked at him. He then tried to assure me that he had studied nutrition and that we should respect their choices. Their midwife, who had called me, felt that the baby was getting dehydrated and loosing precious ounces that he should have been gaining by now. The father would not let us visit with her unless he was in the room. We both spoke to them rather firmly, hoping to wake him up a bit. She had already given up any autonomy she may have possessed, though I doubt she ever had any, at least since she met him. When I called the next day to see how they were the phone had been disconnected. The midwife went out to their house and was told by the landlady that they had moved out that morning. They were gone. Vanished.

I slept in and called the hospital once I was awake. The nurse told me that they had just had a healthy 8 pound girl. The midwife came in after she heard I had left, though they were instructed to say she was just a supportive friend. She helped them try different positions that helped baby along, which they were very glad for. Later that evening I called the couple and asked if I could visit. I congratulated them and told them how glad I was that they had been able to have the natural birth they wanted. She was nursing which her baby took to right away. She was still 5 weeks early but was doing really well and did not have to go to the ICU. I was so glad all the drama was over.

I got a call from another woman who was living in their communal house two days later. She explained to me that public health nurse had come by to make sure the baby was doing well. She looked at the baby and voiced some concern about his color and that he seemed to look jaundiced to her and also that his skin appeared dehydrated. They had read all of the natural birth books
and said they had chosen to nurse on demand,meaning only when he awoke or fussed and asked for it. They had thrown out the doctor’s program for preemies in which he insisted upon waking the baby to eat every two to three hours at the most until she reached the due date. He had explained that their baby may act very sleepy and need to be fed to catch up, whether she appeared interested or not. But they thought the doctor was just going into some routine medical jargon and that they thought ‘nursing on demand’ sounded more natural. Never mind that the baby came 5 weeks early! Or that she was sleeping up to 6 hour stretches and did not cry. The nurse took a blood sample and explained that they needed to know what the bilirubin numbers were and she would call back later that same day after she got the results from the clinic. They added her to their list of ‘establishment’ care providers, turned off their cell phones and went back to sleep.

Their baby did have seriously high readings for jaundice and she was in the danger zone for being dehydrated. When the nurse called both numbers over and over and they didn’t answer she did what she felt she had to do. She called Child Protection and explained her concerns which were bordering on dire at this point. They had to re-hydrate this baby now and get her under lights right away.
So a police car and an ambulance pulled up in front of the commune and I get a call explaining all this. I had told them I was a lactation consultant/educator and would gladly give them any help they needed 24-7 and they knew I wasn’t charging them, so why didn’t they even ask? Later that night I went to the hospital and sat with Juliette for a while. She was nursing her baby and had moved into the NICU. The hospital gave her a room with a real bed so she could stay right there. She told me that they just assumed newborns sleep a lot. They thought she would let them know if she was hungry. I explained again that she is premature, that the rules all change at this point. She said, sounding surprised, “Oh. That is what the doctor keeps telling us, too!” She was still pretty shaken up by the whole experience. It didn’t help that she had not slept since labor started, going on day 4 now. She also told me she had decided to stay in the hospital this time until everything was taken care of and they understood what they needed to do, even if her partner didn’t agree with this. 

I still see them from time to time. Luna looks too big for her little mama to be carrying her around anymore. She is very sturdy and has gained beautifully. Juliette is feeling well and taking care of herself. It was another example I could chock up to education. I don’t know what I could have done differently. I am just very, very grateful everyone is OK now.

As a doula I think back to experiences like this one and wonder if I could have done anything differently. I think not. I wanted to respect them even when our values differed and I wanted to advocate as much as possible for what her wishes were. I did not feel at any time that it was my place to act as marriage counsellor either. These were two adults whose ideas were different from mine, which did not make mine better or more valid. I come away from experiences like these convinced we must above all respect each woman we work with and allow that their point of view may not be our own. But I have also learned that I must have my own boundaries and equally respect those. Welcome to the world of doula!

STAY TUNED! This and other stories will be appearing soon in the book Call The Doula! a diary© - by Stephanie Sorensen

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