Monday, December 14, 2009

Dealing with Anger

I am so curious to know how other doulas cope with situations in which their clients are being treated very poorly within their chosen place of birth. I have my ways, and so far I am still allowed to work in hospitals, so in some ways I'm doing okay. I am working on trying to make sure those ways don't cost me too much emotionally.

In some parts of North America, doulas are welcomed into hospitals and birthing centres with open arms, and valued as crucial members of the birth support team. In other parts of the world, they are not allowed in. Here in Montreal, I am blessed to work with really great people, most of whom I trust, and who trust me. But this is not true, unfortunately, for doulas in general. I think it's more because I am a very familiar face at most of the hospitals around here, and I work with great caution, meaning I practice delicate diplomacy. In many ways, this has great benefits, because my clients get to birth within an environment of peace most of the time. There is not an undercurrent of ugly conflict and hostility between doc/nurse/and doula. This is extremely important to me, because obviously, this is not the ideal atmosphere within which to give birth. The more I keep things conflict free, the more I am trusted, the better the environment is for my clients, the happier their births, and my welcome in the hospital is continued. But it does mean there are times I have to suck up a lot of nasty stuff that's not so good for me either. I do it for my client's well being, and work hard to process the nastiness so it doesn't stick around inside me.

Alas, I get told a lot by various members of hospital staff, "before the patient came in, they called in and said they were bringing their doula...we were all rolling our eyeballs and getting ready for a fight, but then we saw it was you, and thank goodness, we can relax now, because you're fine...we like you." This sentence does not stoke my ego, believe me. It makes me really sad that there are a lot of doulas out there, trying to establish themselves and their good work, and are being held in prejudice before their feet get off the ground.

Unfortunately, because we are under a lot of scrutiny, it can only take one or two incidents to put staff members off doulas. I am privy to some stories medical staff relate to me about some behaviours that are not going to help our doula cause at all, our cause being to create a safe emotional and physically comfortable environment within which our clients' births will unfold as naturally as possible, if this is what they wish and what is meant to be. A lovely nurse came up to me a few weeks ago and said, "there is a doula who came by yesterday, and every time I came in to look at the monitor or put up the Synto (synthetic oxytocin), she's get in my face and say aggressively, "what do you think YOU'RE doing?" This nurse told me her feelings were hurt, and she hated coming into the room and being criticized for doing her job. Because after all, if she doesn't do her job, whether the doula likes it or not, the nurse will get in trouble. Another nurse told me she walked into the room to see a doula doing a vaginal examination because she thought the resident's exam was incorrect. In our neck of the woods, it is not legal for doulas to do internal examinations. This crosses the line into midwifery. Now, if some doulas out there do do exams, that's their business, but to publicly do it in supposed defiance of a medical person, is not a good doula move. Other staff members tell me, "the doula told the mother to stay home with her waters broken for 48 hours." Whether that's true or not, it is so important for medical people to know that it is not our job to tell women to do this. Our job is to explain what is expected of them by their doctors, honestly outline all the risks the medical staff are concerned about, have the clients do their research if they do not want to follow those protocols, and then let the mother make her own informed choice. It should always be extremely clear that we don't tell our clients what to do.

The way I figure it is this: our clients are choosing to give birth within a medical environment because this is where they feel safest. This is how THEY feel, whether we as doulas agree with them or not. They are hiring us to be a sounding board for information, a person who stays with them the whole time, and someone who will care for their needs for emotional/physical comfort. This means they are, to some extent, willing to accept some of the rules and protocols of their particular hospital in exchange for the security they feel by being there. If they were against everything the hospital stood for, they would find other choices. If they say there are no other choices, it's not true...there are almost always alternatives we can guide them to if they wished. If a client is completely anti hospital and has to go there anyway for some reason, we cannot get into that whole 'fight the hospital" thing with them. We can't make them even more frightened of being there than they already are. We can't come in with them like Don Quixote with the intent of doing whatever we want. It's bigger than we are, and our attitude will make overworked, usually well intentioned staff members stand up on their hind legs in defence of their work, and this will not translate into the most compassionate care possible for our client, which is what we ultimately want, or should want. If we are going in there with the intent of trying to change minds by choosing a more confrontational approach, we have to know nobody is going to suddenly get a look in their eyes like they just got a bucket of cold water over their head and say, "oh, thanks...I've been so wrong all this time. Thanks for opening my eyes." This is NOT me criticizing the benefits of confrontation at times, honestly. It is not to say our beliefs are wrong. It is just me saying that in this situation, where it is known that just by hiring a doula the client is already making a statement that she wants some extra care the hospital is not able to provide, it doesn't take much to make the situation tense and defensive.

So what do you do as a doula when things get ugly, no matter your great intentions and careful behaviour?

Before getting into that, I just want to give credit where it's due. Doctors and nurses are extremely hard working people. We have a terrible shortage of medical staff, and, not getting paid close to what American medical people make, they are working their tails off. I also want to emphasise the amount of responsibility these people have. It is all fine and well for us as doulas to be against many of their choices, but we are not coming from a place of clinical responsibility. Even in Canada, grief stricken parents do blame doctors for bad outcomes, and do sue. These fears, not to mention challenges with insurance companies, add a lot of fuel to the already incredible responsibility these people have. For example, a guy I work with sometimes, a stellar doctor and really good man, sent my clients for an induction. The baby's heart tones had not been so great in the regular prenatal checkup, and the non stress test had shown some concerns, though nothing that sounded out signals of "emergency". I met up with the doctor in the hall and said, "you must be really concerned if you are sending them in for induction." His answer always sticks with me. He said, "I hate having to put them through a procedure they clearly don't want. I'm aware of how much harder it is and some of the risks involved. Do I think I can send them home and most likely everything will be just fine? Yes. Can I as a doctor? No. Because what if, God forbid, they come back, and there IS a huge problem, and I didn't do my job, as aggressive as the choice for induction is, to ensure the safety of the baby when it is true I saw some things in the heart tones that were a concern? What happens to them? what happens to me?" You know intellectually the amount of responsibility a doctor has, but to see it in his eyes, to know it in your heart, is a bigger thing. It actually created a lot more compassion in me for their struggles. Obviously, this doctor's patient chose to induce. She had a painful labour, chose and epidural, and had a beautiful vaginal birth in a supportive environment. Do I dislike induction? Yes. Did I try to change this woman's mind? No. I trust she is smart enough to make her own decisions. I'm just there to support whatever presents itself, not just the things I wish for.

In my experience, most OBs, family docs, and nurses are like the man I mentioned above... concerned for their patients' wellbeing, struggling between what the patients want and what they feel are safe options for a safest outcome. There is a lot of work to be done about certain medical protocols, certainly. Even a lot of doctors agree. So holding them in contempt in our hearts, even if we don't act it out, can hurt the birthing environment. My wise and wonderful doula colleague Rivka has a saying I try to live by: "when you enter the birthing room, come in as clean as a newborn baby." This means don't be judgemental. Don't be on the defensive. Cultivate openness and compassion as much as possible, and if something bad comes up, manage it as non-confrontationally as you can.

So back to that: how do we manage when things are not feeling good in the room? There is a Facebook group out there called "My OB said WHAT?" It is shocking and at the same time entertaining. A lot of wounded women get to get their feelings off their chests and receive support for the emotions surrounding the thoughtless things that are said to them, so I understand the impetus to post those things. I do want to re-iterate, though, that we should see those sayings as being from unaware or unkind individuals, and not look upon obstetrics as something evil. We would feel bad as stellar mothers to have something out there entitled, "My mother said WHAT?" and have bad things we may have said to our kids aired out, even if we are good overall, or the words of bad ones reflected badly upon us as a whole.

So now I will share a few terrible things I have heard and seen, and how I tend to cope.

A client, dilated nearly to fully, all on her own steam, feeling great about herself: an OB goes to give her an exam, and knowing how much she is bothered by cervical examinations, I hold her hand, and prepare her by having her take some slow breaths. The doctor looks at me scornfully and says, "it sounds like you're preparing her for the worst." The client picks up on his tension, and finds the examination very painful. He says to her, "what's with all this huffing and puffing? If you react this way from my fingers, how do you think you're going to get a BABY out of there?" I'm thinking, "did he just SAY that? Did I hear this clearly?! Is this person really that insensitive, or am I on PUNK'D" The room goes silent. He walks out, demanding more fetal monitoring, obviously clearly believing these natural birthing people are being cavalier about their baby's wellbeing. The mother is MAD. The father is irate. What do I want to do? I want to run out of the room, jump on his back, claw with insane fury at his face and ask him if he has ever experienced rough fingers in HIS almost fully dilated, un pain medicated cervix. I want to hate him with all my guts and put curses on him. I want him to break out in painful zits all over his bum. I want nothing good. Would this help? No. Would some pithy, put-him-in-his-place statement clear the tension? No, because he is clearly not into this whole natural birth crap, and already think we are walking criticisms of his work, even though we are not. Well, not 'til then, anyway. So what did we do? When he left, I looked at them, and suggested we all take a really deep breath. We each vented our pain and frustration at his words together just to release the tension. Then I suggested for the time being, we let it go, and make sure we be as friendly as possible to him to make sure he has no excuse to continue his rudeness. The nurse encouraged the mom and dad to think about making a formal complaint later, which they did, but for now to forget about it. I imagined, which I do when I'm really upset, that I'm a dragon, and I breathe all my anger into a fireproof bag that I fold up and place on a shelf until I can open it and do something with it in the future. When the doctor came in and saw the patients had agreed to the monitoring, he seemed to relax and know he wasn't dealing with what he deemed crazy people. When he saw we were actively friendly with him, he relaxed and had a much better attitude. This is not to say anyone excused his behaviour or became his pal, but we refused to let his mistrust and negativity poison the environment anymore. By choosing to treat him with respect in spite of his own lack of respect, we were taking the higher road, creating a clearer energy. Had we remained in a state of victimization or fury, the birthing environment would have gotten increasingly polluted. This wasn't easy for me, believe me. I had to take a little space to hold his image in my mind and force myself to wish for his wellbeing, to send him love as a fellow human being who was going to witness and help with this sacred event. I had to remind us all to love and accept ourselves in the moment instead of buying his words, which were HIS words, based on his fears and shortcomings. In short, we dug for compassion.

One birth several years ago was particularly challenging near the end, not for any physical reasons...the mother was birthing like a champ. Her doctor was not a natural birth advocate at all. He paid lip service to it prenatally, but when it came down to it, he didn't have experience with or believe in the fact a woman could do it naturally. So when he came in to "deliver" my client, he began, without any explanation, to give her a pudendal block. This is some scary old school pain blocker, nothing which my client wanted. She had no idea what this big needle was, and was unaware what was to happen. I leaned over to her and said, "your doctor is about to give you a medication which...." I was interrupted with an explosive yell at me to keep quiet. Unbeknownst to me, before this occured, the doctor had taken the father out of the room to tell him he wanted me and the prenatal yoga teacher who was with us out. The doctor was angry because our client was unmedicated. The father was an incredible advocate for his wife, and said, "these women have helped us have get to full dilation naturally. They are staying, and there's no $#%^$ debating it!" When the doc told me to shut up, I shut up, because there was nothing I could do about this needle going into my client's vagina. When he started guiding her to push, I was by her ear, whispering calming words. Again, he yelled at me to step away from his patient, that I was getting in the way of her being "coached". He got out the scissors to do an episiotomy and forceps. I was absolutely powerless to stop this horror show from unfolding. I was debating stepping between the doctor and my client, or yelling FIRE or something drastic, the anger and helplessness building. I was overwhelmed by the misery of powerlessness and fear for my client's body. Then I looked over at the yoga teacher, and I learned in that moment where my power lay as a support person and space holder. She had her eyes closed, and I could feel strong waves of love emanating from her. I saw with clarity what she was doing, and decided, for the sake of the baby, to quickly follow suit. I took my rage, nausea, and horror, and transformed it into love for that doctor...for the mother who was giving birth, for the father, who was now being held up by our yogini friend because he too was overwhelmed by what he was witnessing. She was whispering into his ear. We all joined our intentions together to create the most peaceful, loving environment we could for the arrival of this sweet, innocent being. We needed to clean up our rage at what we could not in the moment control. We could not linger in the victimization for now. We HAD to transform it, and the only way was to intentionally love. This may sound like a weenie thing to have done, but I swear to you, it worked. The doctor delivered this baby, for no reason known to us, by forceps...thank goodness he was very practised and skilled with this procedure...and the baby was well...a peaceful, beautiful little soul. Strangely enough, though Dad, the yoga teacher, and I were traumatized by what we had witnessed, the mother was not. She seemed to take it better stride than anyone. I am wondering if the collective web of energy we wove around her and the baby helped the trauma not anchor itself into her experience. I don't know. But I do know that from that time on, I chose to deal with these situations of powerlessness with active non-violence.

I saw a mother do the same thing spontaneously once. Again, it was a natural birth, and the doctor came in and said, "I'm going to cut you, otherwise you're going to explode." Now, what a lovely image for a birthing mother to have in her mind as her baby crowns. The medical student, who was gently sitting there, allowing for a nice long crowning, said, "I think she's stretching really nicely, actually." The doctor became irate, snapped off her glove, crossed her arms, and said, "well, then why am I even here at all? If you all know everything, you can just deliver your own baby!" Crickets chirping in the room. Then the dad lost it. He started screaming, "How DARE you talk to my wife like that when we are giving birth, what is WRONG with you?!" The mother, dreamy eyed with endorphins, said, "Honey, it's just her stuff. Let's just focus on having our baby peacefully." The doctor shut up, the father calmed down, and the med student had the most beautiful smile when she caught the baby and discovered absolutely no tears to the mother's perineum...not one teeny, tiny little "explosion".

I have a lot more stories like this, sadly. But the point is that they ended well. In choosing to be calm and loving, instead of angry and confrontational, which would surely have felt good in the moment, I feel we helped create a better environment for the baby and reduced stress for the mom. Yes, by birthing in hospital we risk these situations. But luckily, they are rare. Most of the care my clients receive is respectful and compassionate, and I am truly grateful for some of the life saving interventions I have seen in my years of practice. A doula cannot control everything that is done, but we can help to mitigate some of the emotional risks.

So what do I do with those fireproof bags in the end? I go into a safe space, open them up, and let the emotions come out. I release them, and envision them transforming into a greater capacity to love, a better ability to hold difficult situations with peace. And then I write about it.

I leave you with a song I absolutely love by K'Naan, who was born and raised in Somalia, one of the most violent places on earth to live at the time. He speaks of his mother, who even though she was beaten and threatened with her children being taken from her, she gave those who harmed her prayers. K'Naan thanks Africa for his hardships for making him capable of giving. He talks of creating his own medicine by processing the worst situations he's lived through. I am moved by that humbleness, and think there is wisdom in choosing peace where we can.

http://www.youtube.com/watch?v=DIhm94a-8SE