Saturday, June 25, 2011

How Medical Professionals Can Improve Birth Experiences

While we have many benefits to our maternity care system, even medical practitioners will tell you that there are also many flaws.

As a doula, while I work within this system helping women have the best births they can, I am not of it. It is my job to do my best for my clients, using the more grassroots skills of birth supporting to facilitate their normal labours, while respecting the parameters of the hospital protocols and policies. As most who have birthed within this system know, the hospital routines do much to disrupt the flow of normal birth, making the job of the mother (and doula), extremely difficult at times.

I believe in being realistic. Obviously, we cannot at this moment in time recreate the environment of Ina May's Farm, with its amazing birth stories and outcomes. As a doula I cannot make the system suspend their routines. Even if the doctors and nurses wanted to, they themselves are bound to work within the rules of the environment. So for now, it is what it is. I believe in improving what exists right now before projecting into my future vision of the perfect hospital birthing centre. It is by grounding ourselves fully in the now and keeping our feet planted on the earth that we can reach for the sky. My mandate is to work with what exists in our immediate situation.

Right now, even within the limits, there are ways to improve maternity care, contributing to the safety and enjoyment of a family's birthing experience. It is my hope that by witnessing the evidence resulting from these changes, the new generation of medical maternity professionals will begin to create change to the infrastructure of the hospital system in conjunction with the powers that be that make a hospital run. Big dreams, huh? But why not? I believe in ripple effects and morphic resonance. I believe that our birthing functions are highly influenced by our culture. Culture is something that can be created. These are my humble suggestions of what medical professionals can do to contribute to the healing of the hospital birthing culture and improve birth outcomes.

1) Understand Normal Birth

Normal doesn't refer to how about 98% of babies born to first time mothers come out, which is with the mother epidural-ed and on Syntocinon (Pit for you Americans). This type of birth is marked down on records as "normal vaginal delivery", but it is not. It may be considered normal because that's what usually occurs, but given how the body works and the dance of amazing hormones and mechanics that must align to get a baby born naturally, this scenario is anything but normal. In order to change hospital birth culture, we must get back to the original definition of normal birth. "Natural" birth does NOT mean "vaginal" birth. A natural birth is one that is for the most part ummedicated. I won't get into variances much here, but personally, I believe if a woman receives some Synto at some point in labour, as the environment impedes her own natural flow of oxytocin, and she births with no epidural, that goes down as a natural birth in my book. Purists would argue, but remember, I'm talking hospital birth.

I feel that student doctors and nurses should shadow a midwife or doula, someone who's cultural view of what normal birth entails is different from theirs, in order to witness how labour really works.

Though obstetricians are absolute experts in dealing with our birth emergencies (and God love 'em for it), the vast majority of them have never hung out with a woman from near the beginning of her labour to its end. They have not sat with her prenatally, discussing some of the factors in her life she brings to her birth experience, understanding her fears, concerns, and hopes and listened to her at length. They are not aware of some of the emotional issues she has that could potentially impact her labour. They know labour from walking into a hospital room, asking questions, reading monitors, checking dilation and fetal position, and "delivering her" when the time comes. They don't come to her home afterwards and hear what she has to say about it, how she feels, how the experience changed her life (for better or for worse). Medically, labour is something that exists within a given set of guidelines, and when birth doesn't fall into those guidelines, a woman is treated with drugs or instruments. Rarely have I seen an obstetrician turn to the very simple things that midwives and doulas know could effectively put a birth back on track. To really be an expert in something, I believe witnessing what its true normal is is crucial to our greater understanding of it. Facilitating a new doctor's witnessing of a normal birth or two without the distractions of being the clinically responsible one in the room is something we CAN implement now. Yes, I know the students and residents are really busy and that they are needed for emergencies. But I have this sneaking suspicion that if they could truly see what birth is in its essence as opposed to its symptoms and pathologies, we may see some radical changes to the hospital birthing culture, leading hopefully to less emergencies.

2) Acknowledge How Sensitive Birth is to the Environment in Which it's Contained.
Most doctors acknowledge that stress plays a huge part in the etiology of many of the prevalent ailments we have in the modern world today. They prescribe reducing stress, some even recommending the benefits of yoga and meditation. They know that exercise releases endorphins and contributes to mental health and well being. Blood pressure often goes down when stress factors are reduced. These are common sense givens.

It is widely accepted that tension can contribute to our digestive dysfunctions, resulting in constipation, diarrhea, ulcers, etc. Stress contributes to sexual dysfunction too, leaving folks with little desire or ability to "perform".

Birth is a physiological function that is both about elimination and sexuality, both functions highly affected by a person's emotional state. Something has to come out, and the woman needs to get into a certain state for it happen normally, surrendering to wavy sensations that make her dreamy and uninhibited enough to move a baby through her vagina without a memory of trauma anchored into her experience.

The hospital environment is inherently stressful. Visible machinery is around to remind a woman that complications may happen. It smells like antiseptic, which is associated with illness. Studies have been done which suggest that changing the smell reduces the rate of intervention. Women are constantly told that they have to be monitored and measured to ensure everything is okay. It is well known in midwifery and doula circles that a dark, quiet, comfortable, private space is one most birthing women respond to well. Birth tends to happen more normally, meaning her oxytocin and endorphins work optimally and she can move around as she pleases to facilitate the mechanical process, when a mother is disturbed as little as possible.

Of course, we cannot ask doctors and nurses to not do what they need to do to monitor a mother and baby the way their hospital dictates, but there can definitely be improvements within the given parameters. There are simple ways to protect the environment for a mother to contribute to her nice hormonal flow, even when there are protocols to be followed. For instance, knocking gently at the door and closing it softly would be a huge improvement over barging in and leaving it open, exposing a woman to all the distracting hospital noises in the hall. Instead of flipping the light on to read machine outputs, carrying a pocket flashlight is an incredibly sensitive way of keeping the environment dark and undistracting. Obviously, nobody is suggesting this if there is a real concern, but for routine checks, why not? Not engaging in idle chatter is also a kind way to leave a mother and her partner the focus they need to get that baby out normally. Doctors and nurses are often very friendly and really enjoy getting to know their patients and making conversation, but interestingly, I find the ones who create a lot of idle chatter and bustle, or who explain every single thing along the way, like "Okay, now I'm going to change your chux pad to keep everything clean...we don't want you to end up with an infection. I just had a patient the other day who had such a bad infection...." have patients who end up needing more interventions.

If you're in the bathroom trying to poop after it's been a couple of days, the last thing you'd want or need is a friendly chatty person on the other side of the door, or worse, opening the door and looking at you, talking to you about the weather. If you were trying to get it on with your partner, having someone barge in with the door hitting the wall as an extra oomph to indicate their efficiency, leaving it open for people in the hallway to look in while strolling by, saying, "Don't mind me, I'm just going to restock a few things...may as well as it's not a busy night tonight," you just mind find your mojo fizzle a bit.



Conversely, making no contact with your patient isn't good either. A nice sit down little visit in which you ask a woman what you can do for her is an amazing morale boost she will appreciate. When someone takes time to check in gently then leave the couple to it, they always say, "Wow, that person is really nice!" Feeling like someone cares about what they may want builds trust, so that if you need to intervene in some way, they know you have their best interest at heart. Doing vaginal exams while on your hospital phone or not introducing yourself before doing some kind of assessment is NOT going to get you in the good books. So if we go back to the poop scenario (and I apologize for that), if someone is having trouble in the bathroom, having someone outside the door who's taken a little time to get to know them saying, "if you need anything, I'm here, but I'm going away now to leave you to it" can be much more security building than feeling like they'd have to call on a total stranger for help.



As a medical practitioner, you must honour that labour is sensitive to these distractions. It's not women being demanding divas...it's the fact that like pooping and making love, the process is easily disturbed. Except that once labour is disturbed, the ensuing problems get treated and the birth itself is blamed for having gone abnormally. No fair. This leaves women feeling like they didn't work. So yes, do the job you need to do, but do it with consciousness towards the environment. Saying you have no time is not a good excuse, because in the end, normal birth is a lot less work for you to deal with than having to set up an IV, do a catheter because of an epidural, worry about having to do forceps, etc. And don't worry...if a true concern is bothering you, rarely is anyone going to mind you turning on a light or having a discussion at that point. That is, after all, your job, and the reason most people choose to have their babies in a hospital...to have the benefit of your skills and expertise. Nobody believes that a good environment alone guarantees a great birth...but you'd be surprised at how simple adjustments to it can put a labour that seems stalled onto a better track and how respect for it can prevent some problems all together.

3) Watch Your Words!

There are some things medical practitioners say that are most likely meant to be funny or inspiring, but often just create doubt and fear in a mother. And what do doubt and fear do? Dampen the hormonal flow. It's very simple. Keeping those hormones flowing happily and easily contributes to better birth outcomes much of the time. You want to PREVENT having to use the tools available, not unwittingly contribute to their necessity once the birth vibe has been disturbed to the point of no return.

Harsh, critical words are rarely appropriate in birth. Okay, if there is a true need, sometimes saying, "Okay, Honey, now it's time to give a REALLY big push!!!" is helpful. But for the most part, sensitive labouring ladies can interpret common comments as criticisms. Again with the sex, but we ladies know there's nothing like the buzz kill of someone saying something like, "oh, Baby, you are so sexy...I totally want you. Oh, look, your boobs are saggy!" It's hard to proceed after that. Or, again with the poop, but what if you had a room full of people staring at your naked butt, you with your knees up to your ears, while they shouted at you to PUSH, and then they told you you weren't doing it correctly, that you weren't pushing WELL. I wonder how much longer it might take than normal for that defecation to finally happen?

Here are some of the phrases that need to be kept to oneself while making a clinical assessment that is perhaps for you a red flag, but has not shown itself yet to be causing a real problem in labour:

"Wow, that's not a small baby, is it?" Women are understandably terrified of birthing a huge baby. The fact that something on average of 7 pounds or so has to come out their vaginae is a concern enough for most. Adding fuel to that fire by that comment will, in Ina May speak, clench up the sphincters. We want those sphincters to OPEN, not shrivel in fear. These words will prevent opening in many women. Poking about inside a woman's pelvis with a doubtful look upon your face, saying, "hmmm, it's not so roomy in there, is it?" is also not so helpful.

I know doulas who have been told by medical practitioners, upon having been taken aside to give them a heads up that their patient has been sexually abused as a child and that certain phrases most people can handle are terribly triggering to a woman who is about to give birth, such as, "open your legs, I'm going to put my finger inside you," or, "you're so tense...if you just relax this won't hurt you so much.", that all that is just hocus pocus. I have had clients told, "If you're bothered that much by my finger, how on earth do you plan on getting a baby out of there?" I heard once in response to someones simple request to be upright in labour, "This is obstetrics. You don't always get what you want. When it goes well, you're lucky." Well, the last time I checked, birthing women aren't practicing obstetrics, they're trying to have their babies. That statement implies, "I'm the one in charge here, not you. You can have all the good intentions you want, but it will probably be dangerous, and I'm the one who is here to save you, so do what I say." How much do you want to bet that created a self-fulfilling prophesy?

Language is incredibly powerful. A doula's magic is often about creating "word medicine" to counteract well meaning but insensitive comments..like the "Gate Theory of Pain Mechanisms," but in emotional terms. Nobody is asking a medical practitioner not to be honest with their patients about their situation, but paying attention to the wording is crucial. I recently saw an amazing example of how a challenging situation was given much hope by a sensitive resident. A client of mine had been labouring for an incredibly long time with very little progress. She was becoming exhausted and frightened that labour would never progress. Being in the hospital, she was now in a situation where medical suggestions were going to be given. The resident said, "you're doing great! You're doing everything you can and coping really well. It's true there hasn't been a lot of change in your cervix for 24 hours, and there is a potential for concern. But in obstetrics, we don't even consider you having a problematic labour until you're having strong contractions at least every three minutes lasting for a good minute. You haven't even gotten there yet, so here are the things we suggest to get you to that point before we even think about diagnosing a problem...." Worded this way, the woman had hope that there was still a lot of room to try some different medical things to get labour moving. Her struggle was honoured, she was praised, and was told not to worry, that there were still options before anyone started announcing the dreaded C-section. This powerful choice of words I feel contributed to those medical tools working well for her and her coming away with a really positive feeling about her birth. It could have been said like this, "You have been here for 24 hours with hardly any change to your cervix. We're looking at a risk of dystocic labour which can lead to (insert horrors here). Clearly you need help as your body isn't doing it on your own, and if you don't choose these things right now you are endangering your baby." Sadly, I see that wording more often that not.

4) Trust the Woman

The body that has forged this baby and that is working hard to get it out probably has valuable insight into what's going on inside her. Even if she happens to be incorrect, it is still worth investigating for her, making her feel respected and heard. A student of mine went into labour at 34 weeks. Because she was very quiet, a nurse kept telling her she wasn't in labour and that she should just go home. The monitor wasn't picking up contractions, so she wasn't believed. The nurse left the room and the baby was born unassisted. I as a doula have actually caught a couple of babies in the hospital because nobody believed the grunting first time mother standing by the bed could be fully dilated when she was just 4 cm 20 minutes before.

It saddens me that many women get eyeballs rolled at them (behind their backs) and get treated like bothers as opposed to the honourable life givers they are in that moment. After a long birth I have had nurses come up to me and say, "how did you deal with her? She was SO demanding!" when I never really interpreted her as anything more than that natural birthing woman she was. Birth is hard. It's even harder having a natural birth in a hospital environment. Many women need to be touched and encouraged a lot. I just find that normal, not demanding. I do that because I love to. When medical staff interpret natural birth as cumbersome, we are lost. I trust women know what they need intuitively much of the time to get the job done. If she wants to stand on a chair because the floor feels cold on her feet, fine. If she wants to sing or howl or moan, great. If she wants to cry a lot to release pain and tension as her cervix blossoms, beautiful. If she wants me to press into the small of her back for eight hours, great! This is my trusting her. Sure, there are times suggestions are warranted because she's caught in the "rock and hard place" space, but even then I think the baby will most likely come out given enough space and time.

When women are forced into a certain position and told how to push, this shows a lack of trust. They are told, "You're baby WON'T come out if you don't push HARD!" They're told if they don't have the episiotomy they will end up torn from stem to stern (which strangely enough, I have almost never seen happen when a woman refuses a non emergency episiotomy...in fact, often they don't tear at all). It is assumed they will lose all control and just squat in a corner and birth there if there aren't some ground rules (really, would that be so bad?). Sometimes it is even assumed that because a woman claims to want a natural birth, she is stating that this is her intention at all costs. This is a very damaging assumption. There is not trust in it at all.

Obstetrics focuses so hard on the pathologies than can potentially occur in the birthing process (and that has many benefits, obviously), that a lack of trust in the normalcy of it develops. There is a terrible lack of trust that everything will be okay if the woman just does what she wants in labour. Really, though, if all hospitals were equipped with Dr. Michel Odent's "salle sauvage" with a comfy platform of cushions, a birthing pool, perhaps a rope to hang on, and the constant presence of a patient woman (a doula or midwife), intermittent auscultation, almost no vaginal exams, and freedom to do what she wants to cope, how much LESS would we actually need obstetricians? If a woman received more trust in her birthing process, I do feel the rate of needed interventions in birth would go down. Isn't that what we ultimately want? It should be. If an obstetrician loves natural birth and wants to be involved in it and not just the complcated cases, that's awesome! Then they are probably part midwife at heart. Maintaining quiet clinical vigilance while having good faith in the woman's body lends well to maintaining the physical and emotional environment women need to give birth within as normally as possible...and hey, if shit happens, they have all the skills and tools available to do what they need to do.

5) Remember that Birth is Sacred

Okay, pour granola over that and add a drop of patchouli if you want. Have your giggle. But it's true. This is the birth of a child, a human being's very beginning. It is the most monumental event in a family's life. Their experience shapes how they parent, how they feel about themselves as birth givers. It affects their lives. It is for a reason that a woman's state is usually one of ecstatic trance when she delivers her child happily and normally. It is so she can fall madly in love with her baby. Be part of that love fest. It's good for your health.

Connect with your patient in a way that will make them remember you fondly. Every day you step into the case room, you have the opportunity to create a positive experience. It doesn't take much more effort than you would normally have to expend. Make eye contact. Smile and say hello. Ask her what she needs. Don't be afraid to offer touch that's not clinical if this feels appropriate. Kind, loving, encouraging words from a medical person are particularly powerful. You will be remembered for the rest of that family's life, as this is a sacred day. If there is one thing I ask you to remember, it is that.

At the end of the day, what interventions a woman may have had during birth will probably not have as much impact on her as how she was treated and how she feels about her overall experience.

I leave you with a personal story to show you what I mean. I'm an old natural birth promotor. I am not into most hospital protocols. I like the squat in the corner approach. When I was pregnant with my first chid I walked into the hospital I planned to give birth in to check it out, walked out and knew I simply couldn't do it there. I felt profoundly unsafe. I knew home birth was my best option. So imagine me during my second labour, after having had a beautiful, empowering, amazing home birth to my daughter, ending up having to transfer from midwifery care to a hospital to receive medical care. I cried a lot standing in the parking lot of the midwives' birth house waiting to get my non progressing butt to the dreaded hospital. I was scared. And lo and behold, I had actually had a really nice experience. I am one of those really lucky ones, yet it would be so easy for everyone's experience to be similar to mine.

I was only there a few hours before my son was born naturally (all be it facing upwards), but in those few hours I encountered a couple of doctors who made the experience good for me. Of course, I arrived at the hospital at shift change. I saw a doctor I recognized from having attended births several times at that hospital. I started sobbing saying I was having a hard time. Instead of freaking out and worrying about ending my suffering and getting on my case that I should have been in a hospital in the first place, she diffused my drama in a wise, motherly way, put her arms around me and actually slow danced me through a contraction! I cannot say how good that felt to be vocalizing into her secure, substantial bosom! She broke my waters for me, which actually did the trick, and I remember her saying, "There, Mamaleh, you were around 4, not you're 7."

She left soon after, and I was so nervous someone not as understanding would come on shift, but I was blessed yet again by a lovely older male doctor. I only remember snippets, but his positive, gentle presence meant so much to me, and I remember it almost 17 years later. I was yelling like a banshee, yelling for an epidural, but refusing one at the same time. Sure, perhaps there was some serious eyeball rolling out at the nurse's station, but the doctor never projected any annoyance of me at all. I was a mess, screaming between contractions with back pain. He wasn't afraid of me in my rawest state. When he needed to communicate something to me, instead of roughly trying to get my attention or telling me i wasn't helping myself all out of control like that, he stood near me quietly and calmly. When the pain took a small break, I'd look at him and say, "I'm so sorry, I'm so sorry, I don't mean to be screaming in your face." He would touch my arm, look me in the eye and say, "it's your second baby, you're nine centimetres, you're almost there. It's hard." He would tell me not to apologize, that he knew it hurt. When my baby finally came out posteriorly, the resident, also very kind, didn't need to hand him to me as I grabbed him by his shoulders and took him myself. I looked at both these respectful, gentle men and told them, "Thank you." They told me I was a champion. Not that I need my ego stoked, but for some reason those simple words validated everything I had gone through to birth that baby naturally (which I don't regret one bit) and the fact that they took a second of their lives to honour my experience remains with me. Frankly, I don't at all remember the several vaginal exams I received. I don't remember being tethered to the machine for the few minutes I pushed. I don't really worry about the fact that my baby needed to be examined because of grunty breathing and was taken away from me for a minute, and I don't remember much of a managed third stage and an iv inserted because I was bleeding.. and remember, I am one of the "routines disturb birth" preachers! All those things I planned to avoid and worried a lot about prenatally when I envisioned my unexpected hospital birth experience pale in comparisson to the very positive emotional feedback I received from the doctors who tended to me. That's oxytocin for you...it makes you trusting. When you reach out and find someone kind on the other side of your pain, the effects are amplified by the presense of that lovey dovey hormone. I wished I could have had my baby at home, but I have no complaints about my hospital birth.

I hope this story illustrates how easy it is to honour a woman's birth experience and how easy it can be to infuse her experience with something positive she will take away with her and remember almost 2 decades later..and probably will forever. It's no matter that the doctors likely don't remember me at all. It means a lot to me that the first hands that touched my son were kind and gentle ones. I feel he probably had a very nice imprint in those first few moment of his life...patient hands and a mother who was made to feel like a champion. Not a bad way to come into the world. You hold the power to create a happy beginning like this too. Whenever you feel impatient or harried, take a second before you walk into a birthing room to take a breath, and focus on the now. This woman in front of you is bringing forth a new life. This is sacred. Please, please don't forget that.