Monday, May 17, 2010

From the Sublime to the Ridiculous

I will try to keep this from being too long winded. You doulas out there..you know how I feel. We are specialists at supporting the birth process, helping maintain a modicum of its normalcy in a hospital environment that at times can be positively nuts. And oh the suppression sometimes. The suppression of anger, shock, sadness, and even fear. Where did all the logic go? Who killed the wise, ancient woman inside the hearts of many medical practitioners? Not all, obviously, but some? The fact that normal, physiological birth in a hospital setting is considered radical, and that some of my ways of supporting birth are considered annoyances in the light of the Holy God of Protocol, weigh on me heavily. I know all of you have hard times sometimes stomaching the environment, and get tired of your questions to try to gently advocate for your clients being met with rolling eyeballs, snide side glances, or outright ridicule. This is especially frustrating when a lot of the things we as support people know to be the truth about birth are published as studies and validated BY medical people. Are we the only ones reading them? It's not like our information comes from the Barefoot Hippie Encyclopedia. In most cases, anyway.

Let me walk you through a few scenarios that illustrate the source of many doulas' ire. I was with a client who was on her hands and knees on the hospital bed absolutely grooving with her contractions. She was in a trance between, and when one came she would open her eyes widely, say, "Oh guys, this is INTENSE!" then vocalize in that way that gives you goosebumps because it is an utterance of pure, unadulterated, feminine power. The yells got more and more guttural. I was just standing there enjoying those baby arriving sounds, not needing to do anything for this woman but protect her space. I could hear whispers in the background..."she won't keep her monitor belt on, and it's very annoying." I understand these kinds of births ARE hard on nurses, because they cannot monitor the woman they way they are supposed to. But another nurse kindly said, "oh, don't worry, I'll just hold the monitor." So she got on her knees on the floor to hold the transducer on my client's belly, and I sent her a silent blessing, as she healed the moment. There is no need to express annoyance. The labouring woman needs nothing else to bear but the intensity of her labour. To feel like a burden or doubt that she's doing okay given impatient comments in the room is hurtful. I would like expressions of annoyance or words that indicate the woman, having an experience of a lifetime, is being a drag on the busy nurse's day to be kept to a minimum. Birth is awe inspiring. It hasn't lost its magic for me in over 16 years of practice. If a woman wants me to stand on my head to accommodate her in labour, I will. HELLO, this woman is giving life, People! She is bringing a new human being into the world! Do we really need a vision of an angel to appear over her head, or a white bearded sky dude to materialize and put a finger over his lips to indicate to the annoyed to shut up and respect the fact that something very special is happening in the room? Because you're just not going to find anything that embodies the sacred in the here and now more than a birthing.

I was with a woman pushing spontaneously her own way. She was a first time mama, labouring like a lioness...making powerful noises, her body doing its baby ejection thing. She didn't need anything but an occasional sip of water. After easing into pushing like this totally on her own without any guidance or examinations, seeming to be having a pretty good time, a resident marched in, made her flip over onto her back, and did an exam, saying, "Okay, now it's fine for you to push..let's get you set up." Inside I'm seething, but as my Navelgazing Midwife blogger buddy says, "Buy a hospital ticket, get a hospital ride." If I'm a hospital birth supporting doula, I have to support what is, not always what I wish would be. When I'm supporting a woman and the environment is especially challenging, I often think of the theme song from the United States of Tara, which is a tv show about the chaotic, sometimes joyful, often devastating life of a wife and mother with multiple personalities. The song goes, "I know we'll be just fine, when we learn to love the ride." But oh, what a ride! You never know when you walk into the hospital what you're going to be met with. Some days everything clicks and converges to support an amazingly lovely normal birth. Other times, it seems as if everyone is in an awful mood and are taking it out on you. Sometimes it's downright violent. Going to the hospital is sometimes like dealing with a whole building with a dissociative identity disorder. I can never promise a client any consistency of kindness or respect there, and that seems incredibly wrong. Should these things not be at the foundation of patient care? It's not that some of people are uncompassionate in their hearts, it's just that sometimes compassion is squelched by duty, overwork, worry, stress, and responsibility, ultimately making the kind treatment of a patient secondary to smooth running of the institutional machine.

I digress...back to my story. This lady is told to start pushing, and on her back continues to do it the same way she has been, emitting nice yells and not holding her breath. The baby is already partially visible. She hasn't pushed spontaneously for long, and already we can the head a little. She is told, "You're not pushing correctly. It's not good for you to waste your energy yelling. It's not good for you to push for longer than you need to. You need to take a deep breath, block your air, force your energy..." yada yada..turn purple, bug out your eyes, hold your breath, strain your perineum. The mother does so and hates it. I whisper to her that she has done a tremendous job listening to her body so far, having moved her baby down without any guidance at all. I try to do this in a way that will evoke no criticism or ridicule. But it's hard. There is such an attachment to one way of doing things, any variation tends to be looked upon as radical and some kind of hippie doula thing, instead of a physiological fact, supported by lots of smarter and more educated folk than I. A nurse heard me and said, "No, it's logical, if you take a deep breath and..." yada yada...pretend you're a pop gun, intra-uterine pressure, must-be-yelled-at-to-not-yell, harder harder HARDER.....NOW YOU'RE PUSHING PROPERLY!!!!! As if those previous independent maternal efforts had been worthless, because they were not sanctified. There is no trust. Did I argue that had she been left alone on her knees she may not have had to have pushed so hard to move the baby down, as being turned onto the back closes the pelvis by 30%? If the baby is trying, in executing her little cardinal movements, to push the sacrum away with her face, initiating the extension of her head, does it not make sense that having the sacrum immobilized between the bed and the head could impede things, and that the purple pushing serves as compensation for this fact, the pulling of the knees to the ear creating a little more space but actually creating a powerful strain on the poor perineum? No, I did not argue, because I had to tend to the lady before me. I didn't want to create tension. That maybe the fetal distress that created a need for an episotomy and ensuing 4th degree tear may have been avoided I truly cannot say...not my place to judge given my lack of clinical knowledge. But I can say the undermining of power and personal preferences of a woman in birth is shocking, and that it seems to me there is always some emergency that comes up and everyone thanks God the mother and baby were in those good hands. And yeah, sometimes that's the honest truth. But a lot of the time I think the problems are created by interference that is supposed to serve as precaution and preparation for emergency. As I get older it gets harder to reconcile that we have not struck a balance and achieved the great outcomes we COULD have, like in the Netherlands, where obstetric care is used for problems, and midwifery care is used for normal birth. When birth is in the hands of those who consider it...well, normal..isn't it interesting how fewer emergencies there actually are. And when the unexpected does occasionally arise, we have those wonderfully gifted OBs to do the jobs they're great at, which is to identify and treat birth complications. I am grateful for their presence, I truly am. But do we always need such hardcore protection for something that is usually pretty straightforward and normal? Isn't it apparent that to turn a woman doing her own thing, bringing her baby down in her own way, onto her back to start poking around and telling her what to do and how to do it is an intervention that probably causes more problems than it prevents?

And the blame. There is so much blame on women and natural birth. The mom is yelling, so she's not doing well and is "out of control". She is "not handling it". How many traumatized women are walking around buying that either their pelvises are too small or their babies were too big? Perhaps in some cases this is true, but I know SO many women who believe this about their bodies, you'd think we would be on the edge of extinction with all the inadequacies of our bodies. A client of mine was told that her shockiness and fatigue after birth to the point of not being able to hold her child was attributed to having experienced the strong sensations (called "traumatizing pain") of labour instead of having been cut and torn completely. And sometimes if something does go wrong in natural birth, the fact that the mother chose to do it that way is implied as the probable cause. Do we realize yet the power we have in our hands with all our great technology and life saving skills is not realized when our attitudes towards women and birth are still medeival?

Let me outline a beautiful scenario to end this rant, moments such as these restoring my faith and joy in the possibility of gorgeous hospital birth. Imagine a woman in the throes of spontaneous pushing. She is dancing and writhing to the rhythm of her own contractions. The nurse is a little frantic, trying to get her to lie down. As much compassion as I have for this actually very nice nurse, it's not my job to make her life convenient. I simply behold the work of my client, offering myself as something solid to lean against and cling to, which she does liberally. In walks a doctor I have not seen...a young feisty woman. The nurse is trying to tell the woman how to push. This doctor is with a resident she's teaching. The doc says quietly to her resident, "you know all this talk about telling a woman to push? Well, studies show we're probably doing the woman a disservice, making her uncomfortable and putting tremendous strain on all of her, including her perineum. It may take a little longer to see the baby, but it's gentler." The nurse suggested to this doctor to "break the bed" to get her pushing "properly" and the doctor efficiently said, "you can listen to the fetal heart, I'll worry about the delivery." She proceeded to tell her resident, "Mothers seem to know what they're doing, and we don't really need to tell them much...our job is to follow." And follow she did, contorting into whatever position was necessary to safely accommodate the woman who liked to move around a lot to give birth the way she wanted. What a beautiful treat for everyone! Why can't it all be like this?

Don't give up, Doulas. I keep doing this job because the incidence of amazingly gorgeous, normal birth experiences in hospitals is on the rise in my neck of the woods. It could be because having been around for a little while and knowing the staff of most hospitals here fairly well seems to help set a tone when I come in with my client. When we're a room full of trusted friends, the energy is good, and we all appreciate each other. There are fantastic medical practitioners who truly do care about the woman's experience of birth, and can seem to balance being accommodating to those needs and providing the medical care they have signed on for. It IS possible. Keep at it, Ladies. We need you! Don't get discouraged. You are making a difference, and I love you all for it.