Thursday, June 24, 2010

You Can't Take the Effect and Make it the Cause

"You can't take the effect and make it the cause," is a saying I quite like, immortalized in a song by The White Stripes.

I have thought a lot lately about the prejudice that exists towards doulas in general. A friend and I were having a discussion with a nice lady who happens to be an OB nurse. I don't want to make people think badly of her or anything, so please don't be reactive...but while my friend and I were making points about some medical practices studies suggested warranted more research by parents-to-be before they made decisions about their care, she responded, "Well, you know everything, then. It must be written in stone because the doulas say so," She at some point in the conversation claimed that if something wasn't medically proven, it was not knowledge. Yeah, yeah, I know, but this isn't the tangent I want to take now.

Please don't demonize this woman, who is a good happens that people get defensive about their positions. If you've worked one way for a long time, believing it's the very best, safest, medically validated way, then it's not fun to have a couple of hussies come along and rock your world with stuff seemingly plucked from the air.

The thing is, we DON'T pluck things out of the air.

Doulas have been around since the beginning of time, doing our warm-fuzzy bit for birthing women and new moms. But in the last few decades, this role has become far more political. Now we are also called upon to be advocates. As the doula profession grows stronger and stronger as more and more women request our services, we are becoming more scrutinzed, criticized, and even ridiculed by many medical professionals, despite most of our clients' excellent outcomes, both clinical and experiential.

Consider this: our modern role developed BECAUSE loads of women weren't enjoying their obstetric experiences. Women were coming away from delivery rooms feeling confused and traumatized about what went down. You've all heard about Twilight Sleep and all babies being yanked out with forceps. It was the women who said, "We need to figure out whether this debilitating treatment of us in birth is actually needed! Were we not born capable of figuring most of this out on our own like those women we hear about who squat in fields? What's wrong with us that we need to be knocked out and cut and without our husbands?" And as the women looked for more gentleness in birth, their concerns being picked up and validated by compassionate medical people, they realized that in the throes of intense labour sensations, they may not have the power to communicate their worries, and were terrified of getting caught in a cascade of interventions they didn't need or want.

Wonderful people, such as Klaus and Kennel, noticed how much better women felt about themselves and their birth experiences when they decided to take another woman with them into the birthing room. Even just the presence of another woman contributed great things to the birth experience, never mind a female who also knew how to provide great emotional support, communication of the mother's needs (not decided for her BY the support person, but translated to the medical staff FOR her if the labouring woman couldn't speak herself), and soothing comfort measures. These researchers took the time to conduct some well known and well documented studies which confirmed their observations. Lo and behold, the presence of a non-medical, nurturing woman in the birthing room drastically reduces the need for medical interventions, as well as the desire for pain relief from labour sensations.

I can kind of imagine how medical people, who have busted their humps to get through the gruelling hell that is medical school, becoming skilled at diagnosing complications and executing amazing feats to spare mothers and babies from death, might scratch their heads and go, "Say what?" when a friendly woman NOT in scrubs asks them, because the labouring couple are clearly very focused on the work of dealing with huge contractions, "if it's not truly necessary to stay lying down, this lady would enjoy walking around to help soothe her labour pain. She would like to have a natural labour if this is how things work out, and being upright seems to help her a lot. Would this be okay with you?" If that doula/mother/partner team do all kinds of strange things together, like slow dance, everyone massaging and murmuring sweet nothings to the mom, who drapes herself in unfamiliar positions chanting oddities like "oooopen!" and even yelling out tension releasing expressions of pain that would fill the uninitiated with fear, you might feel extremely wary. If you as the doctor are simply not comfortable with these shenannigans, having learned a way of managing labour that you are secure with and within your knowledge base and experience keeps your patients safe, you might, if you're not actually impressed by the birth unfolding naturally, feel odd. You may feel usurped. You may feel resentful that the couple seemed to respond emotionally far better to the person with the strange smelling back of doula tricks than to you, who is the one ensuring their safety, for Pete's sake! You may feel downright angry that some chick with her essential oils and hippie talk of breathing away tension came into your delivery room and messed around with your sense of rightness, in your own place of work no less!

We get that. I think it would probably be quite a normal human reaction, considering the doctor is the one in the room who bears all the clinical responsibility. But the thing is, our strange ministrations to these women ALONG with excellent clinical care actually create more favourable outcomes, for doctors, mothers, babies, and partners (fathers or other mothers). Even if medical people want to look at doulas sideways, believing we are puppet masters who pull our clients' strings to make them carry out our evil plots of undermining medical authority, it's important to take a breath and get some perspective.

Doulas do NOT attempt to assume medical care of a client (decent, run of the mill doulas don't, anyway). It may seem like it to a doctor or nurse if a mom is being yelled at to get angry and PUSH while we're smiling at her silently, not joining that enthusiastic cheering squad. It might irk nurses to hear us say, "your body is amazing! It knows how to birth that baby. You know how to do this." Please know this is not a covert attempt to undermine anyone's medical authority, but to execute the wishes of the mother, made known to us in advance. She has spent her pregnancy reading up, figuring out how she wants things in her birthing environment if things go reasonably normally, and discussing those things with us. We open their eyes to other possibilities they may not have learned in their hospital based childbirth education classes, yes, but if a mom is not interested in something, we don't go there. If our clients have different ideas from what is typically done in a hospital, it is our job to lead them to resources that will help them make decisions about their care...we don't tell them what to do, we make sure they've informed themselves from several different sources, so as to better make choices for themselves from an empowered place. We absolutely encourage them to discuss their wishes with their caregivers. Then we support what they want. If their ideas are not sympatico with typical hospital protocols, it is important for medical people not to assume their patients are weak minded, malleable creatures whose minds were warped by the likes of doulas. Patients need more credit than that. In fact, that's probably why we're here, because even up to the latter part of the last century, birth practices were still pretty barbaric in many ways..and women became fed up.

We are not accusing the medical system of being barbaric now, or ignorant as to how to deal with perfectly normal births (though you may find that some women who feel victimized and traumatized by their births and treatment would vehemently disagree). But it is important to understand that the modern doula profession was born from the effect of medical practices that made women feel disempowered.

You can't take this effect, and make us the cause. Good doulas are emphatically not the cause of patients seeking empowerment, looking to birth on their own terms, even if those terms make medical staff feel uncomfortable. Media jokes about doulas a lot. We get many snide remarks from some hospital staff members, like "The DOULA told her to lift her leg while lying on her side, yeah, like THAT'S going to get a first baby out!" Or "There's a DOULA here...I guess now we're going to have to speak in dulcet tones." Or, one of the ones that hurts most, is, "Honey, you don't HAVE to suffer with labour pain! Just because your doula told you epidurals are bad doesn't mean she's right. She can't know that because she's not a medical professional." It hurts because we wouldn't say, "epidurals are bad," and we would never keep a mom from an epidural if that was her wish. It may not be realized by staff that mothers tell us in advance of labour that they'd like to avoid an epidural, and we have ways of communicating with each other so we'll know when she's serious about changing her mind. While the staff may think their ire is aimed at us, in reality, comments like these completely disrespect their patient's wishes, based upon gathering information and making choices for herself that make her feel safe and happy. To take the effect of a mother's choices (to hire a doula to help her birth naturally) and to make us the cause (of her "suffering" in labour), is not acceptable, or logical. Many birthing women here are told, "if you want to birth in that position, you should have given birth at home!" and this is cruel. Do you know how many women in Montreal want to birth at home and cannot because of the unavailability of midwifery care? Some of our clients want to birth in hospital, on their own terms, and some feel stuck with medical care they wish they didn't have to have. Don't point fingers at doulas for those women feeling uncomfortable with the hospital institution.

We're often treated as if we just waltzed into the hospital, having attached ourselves to an unsuspecting couple, just to wreak havoc in the obstetric ward. In reality, we are sought out, requested, paid for, turned to for emotional support and bouncing ideas off, and at the end the relationship are very often told, "we couldn't have had this experience without you." This does not mean our clients were not grateful for their medical care. It just means they are so glad they got that saline lock instead of an IV with a pole so they could be mobile (which often is not's asked for by us or our clients), or that when everyone was telling them they should have an epidural, our voice illuminated the possibility of getting to the end on their own steam. The medical procedures that occur with a woman who wanted a natural birth are usually secondary in a new mother's experience to how she felt she was treated.

I try hard in my doula career to come into the birthing room as clear as possible every time, letting go of past traumas and challenges. I try to always let bygones be bygones, and stay focused on the task at hand to help the woman I'm with according to HER needs. If a doctor or nurse has in the past been burned by bad doula behaviour, I would appreciate not having that effect turn me into the cause of this particular patient's "non-compliance". I do not take past TERRIBLE things I may have seen and hate the medical system for it. My gratitude for Medicine to diagnose and intervene with complications is profound, and the bad behaviour of some of its practitioners will not kill my respect for it nor the women who choose this institution within which to give birth.

The truth is that doulas and medical practitioners working together represent to most women in our North American birth culture the best of both worlds for their birth experience. It behooves us to foster respect and compassion for each other.

If you'd like a little entertainment, check out the actual song I'm referring to, just for fun!

"Effect and Cause" The White Stripes

Saturday, June 19, 2010

The Birth of Finn

June 19th is a beautiful day...the day my baby boy was born. He has been my baby for five years.

As an experienced doula, I receive a lot of curious questions about how I give birth. When you’re labouring, you cease to be anything but a birthing woman, dancing with the intensity of the experience, same as everyone else. I practice what I preach: I take yoga classes and have doulas at my own births.

I have always suspected I would have four children. When I turned 35, I figured, “Okay, well, I started having kids at 22, so I guess since I haven't had any more, I'm going to decide to stop now. I'll be happy with 3.” I got pregnant a week later. Circumstantially, it was a challenging time to get pregnant (when isn't it?), but sensing that happy little spirit in there, I was truly overjoyed. I would tune into the little one and feel such a rush of good energy.

Expecting the birth of my fourth child, I was actually more anxious than I had been for the others. My first labour had been normal until it came time to push out my baby. She was born “sunny-side-up” after nearly three hours of pushing, but luckily I had a patient midwife and was able to squat the whole time to bring my daughter down and out. No tears. All was well. I gave birth to her at home, and had I not, my midwife was positive I would have ended up with a C-section, especially being bound to deliver in the “traditional” position. All in all, it was a phenomenal experience. I felt immensely empowered as a young mother.

My second child decided to come early. I was planning to have him at the Birth House with midwives, but I was slightly under 37 weeks when I went into labour. I was allowed to go there anyway providing all was well, but after a very long, challenging active labour with very little progression, I was asked to transfer to the hospital, and I felt okay about that. I gave birth there a few hours later naturally, but I was pretty exhausted from having had such a long birth (again a posterior baby) as well as a substantial bleed.

My third child was a planned homebirth, and thank goodness it was planned because it would have worked out that way anyway. Contractions came on hard and fast. Because of the previous labour, I figured it was just going to be hard and long again, but lo and behold, 43 minutes from the very first contraction, my baby girl was born into her Daddy’s hands. The midwife arrived several minutes later. It was wonderful. I attribute it to the yoga postures I practiced religiously in order to prevent a posterior baby, as well as receiving osteopathic work.

As the time to give birth to the fourth child came closer, I became more and more anxious. I knew what my body was capable of. I began to be afraid to go outside. I was scared that I’d give birth any old place, like in the grocery store. Every time I felt a contraction (and I tend to get a lot of contraction activity in my last month of pregnancy), I was worried that this might be it. My daughter was being filmed for a tv show during my late pregnancy, and I started having a few contractions that were making me wonder if this was it. This is pretty normal in late pregnancy as the uterus warms up, but I panicked! I thought I was going to have to grab her and leave. Images of birthing in the green room of the tv studio or in the car during rush hour went through my mind and filled me with fear. My midwife Isabelle told me this was pretty normal for women who had experienced extremely fast births. My doula self knew my body would wait until I was in a reasonably safe place, but my pregnant mama mind was wary.

On June 18th, my waters broke. It was just a little trickle, nothing to write home about. It was clear, but I knew it was amniotic fluid because whenever I went to pee, I could see little flecks of white vernix in the toilet bowl. I was debating telling my midwife this, because labour had not started and I didn’t want to get her into any trouble by refusing to go to the hospital after a certain amount of time. In many other countries (who have better neonatal outcomes than we do), the waters breaking is not treated as such an urgent event. Inductions are done regularly here, and I was not going to have any of that. I’ve seen enough inductions, and that option didn't sit well with me at all. I felt safer and more confident waiting, without receiving any vaginal exams. I trusted Isabelle, and told her what was going on. I didn't know my strep B status, and figured I'd ask her since my waters had been broken for awhile, and she confirmed it was negative.

I spent the day a little anxious because a) I knew labour was going to start, most likely within the next day or 2, and b) I knew, given my history, that it could be really long or really fast. The good thing was that this time I had warning of labour, so I was able to get my younger children out of the house for the night. At my last birth there had been no time for that, and I worried about them listening to me yelling my head off and being scared. More than anything though, I just felt like I wanted to have the space to focus.

I went to bed that night and had a great sleep. Seriously, it was such an amazing sleep, I'll never forget it. I don't know if I've had a sleep that good since Finn was born, and given that my insomnia is especially bad in late pregnancy, it was a shock to awaken in the morning without having gotten up even to pee. The body knows what it needs, and it never ceases to amaze me. At 5:30 am I had an strange sensation that felt more like the beginning of a bladder infection than a contraction. It passed after a couple of minutes. I tried to go back to sleep. Then, at 5:45 am, I began contracting for real. Wise to the fact that my body felt like it was gearing right into good labour without the warm up of early labour, I got up. My husband roused a little and I told him, “This is it!” and suggested he rest up a little more. I got up, puttered around, and he got up excited that he was going to have the greatest Father’s Day gift ever.

We had a nice time, getting the coffee beans ground up, getting the kettle on for tea, and seeing that the morning was going to be beautiful, after days of rain. It felt like a magical day to have a baby, and oh was I looking forward to my baby! After about 20 minutes of labour I knew I had better call the midwife if I wanted her to make it to the birth. She asked if my contractions were very strong yet, and I said, “They’re getting there.” It takes her 30 minutes to get here from her place, so she said she was leaving NOW. My husband Mitchell and I went into our eldest child’s room and told her that I was in labour. We asked if she wanted to stay there or go to her friend’s place, and she said she wanted to be in the house, but not in the room as I was giving birth. She had been really into seeing her baby sister born when she was six, but at 13, the thought of seeing her mother give birth wasn't as appealing. She decided to go back to sleep, close the bedroom door, and turn on the air conditioner so she wouldn’t hear all the goings on in the house.

As for doulas, my original plan was to have my beloved friend and backup doula partner Rivka be with me, but she had left for Italy just a few days before I went into labour. I had many of my wonderful doula students who were prepared to come at the drop of a hat, and in that moment I decided that I was going to have Sharon and Sarah. They are very close to Rivka, and they knew I was sad about her not being able to be there (as was Rivka), and I knew they would bring her along in spirit. Also, during my pregnancy they gave me such a huge amount of love,that I felt I wanted that surrounding me. They visited me, bought me great big cotton underpants when I complained about growing out of my regular ones, they stroked my belly, laughed with me, and I knew they were already in love with the baby. Sarah was 10 minutes away, so she showed up first. The midwife’s student came next, and Sharon followed, immediately taking me into her warm embrace. I felt like I could crawl into her lap and purr.

We turned on some mellow music, and I got into labour land. I didn’t feel I needed any input our touch, just some really strong space holding. Sharon and Sarah smiled and sat there, which was all I wanted. It was what I needed. What I needed the most was my husband. With every contraction I fell into his arms and it felt so GOOD to be in those big arms, saying Oooooooo (my wolf noises, he called them) and “I love you I love you I love you”. The contractions were painful in a way, intense for sure, but actually a lot of fun. I was enjoying myself, getting into my groove. I was enjoying surrendering to birth. It felt much gentler than my 43 minute bungee drop of a previous labour.

When Isabelle arrived, the midwife/doula effect kicked in. I’ve seen it before. When I show up at a woman’s birth, the contractions often pick up in strength and frequency. Well, the same happened when my midwife arrived. Things got faster and stronger, but it was still fun. I still had an awareness of my surroundings between the contractions, even a sense of humour at times. I felt completely safe within my little nest of good women, in the arms of my husband. I noticed that if I breathed right into my belly and let the air stay in there for awhile surrounding the baby and giving my uterus oxygen, there was much less pain. It was great to experience directly what worked for me instead of worrying about “techniques”. I remember Clearlight, my pre-natal yoga teacher, telling the class that listening to one’s own body and letting go of “techniques” was a better way to flow with labour. The tools we learned were guidelines, meant to be adapted and used creatively by each individual woman. Another thing I had really wanted to do during this labour was to stay absolutely present, concentrating on the sensations instead of trying to find mental tricks to disassociate from them. The mantra I kept playing in my mind was, “Accept it all”.

After a particularly strong contraction which had me starting to squat lower to the ground and do some loud, low, uncontrollable vocal toning, I think I asked Isabelle if she wanted a coffee. Mitchell told me after the birth that she said she would have one later, because she didn’t think she’d have time to drink it then.

I remember thinking, “Wow, if I’m going to have the baby soon, this will have been a breeze of a labour,” The next contraction, I felt a slight movement in my tailbone. Not that rectal pressure that heralds the baby’s imminent arrival, but an opening of my sacrum. I asked if anyone wanted to use the bathroom, because I was ready to do what I usually do during transition, which is to get myself under the shower with all the lights turned off. To me there is something primal and comforting about being in water in the dark. Isabelle went into the bathroom, and while she was in there I didn’t contract once. My body was waiting for me to get into my inner sanctum. When she got out, I turned on the shower, turned off the light, and got in. I didn’t want anyone in there with me. I’m a pretty private birther…I like knowing that there are people right outside, but I need privacy to allow my animal self to let go and cope with the storm of transition.

I immediately crouched down low in the bathtub and suddenly the baby made a big drop down. I felt my bones open and the baby's head pressing hard. So much for a breeze of labour! Wow, it was intense, more intense than I have ever remembered labour sensations being. My husband came into the bathroom, just to sit there and be with me. The next contraction had me vocalizing so loudly, I was sure I was probably scaring my birth attendants (though in perfect trust of me, I found out later they were all just standing outside the door smiling and enjoying my baby arriving sounds). I felt like I needed to project my voice to its maximum level. I imagined that by doing so, I could make myself bigger to cope with the hugeness of the sensations that were taking over my body and mind. Between contractions I kept “accept it all” in my mind, but admittedly during those transition sensations, I thought that if it continued like that much longer I might just be tempted to jump out the window. Wow. I will NEVER forget those few contractions. Ever.

I was SO thirsty as the adrenaline rush that women get before it’s time to birth started kicking in. It made me happy, because I know I always become consumed with thirst right before I start pushing. Mitchell handed me water. I was so glad to have him there. I guess after about five or so of those Tsunami contractions in the bath, my body started bearing down a little. I knew instinctively I was still in transition and not totally dilated yet, but it was getting close. I just let my body do what it needed to do. It pushed as I yelled. I begged Mitchell to tell me he could see the head. He couldn’t, but reassured me that it would be there soon. Bless him, I put all my faith in that statement. The beauty of birthing several children together is how well he knew me, my sounds, my behaviours….he was such a comfort. I checked inside myself for the head, but it was still pretty high up there. I was thinking that I just couldn’t do it much longer, whatever that meant. I mean, really, what choice was there? I was adamant about not giving into the urge to try to get away from the pain, so I just focused on the incredibly loud sound of my voice. Breathing my way Zen like and hypnotically through this would have been completely impossible. After a couple more contractions I checked for the head again and could feel the baby much lower. The sensations began to change from pain and pressure to deep pushing urges. Instead of yelling I was now grunting. Ah, relief, because the more the pressure built, the less it hurt.

Mitchell asked me if I’d like to get out of the bath to have the baby. After all, there wasn't even water in it. I was just lying in the bath with shower water sprinkling me. I did want to get out of there because I wasn’t at all comfortable any more. I felt like I couldn’t open up my legs the way they wanted to open, and the porcelain was hard and unyielding. But I didn’t want to move because I was just so consumed. “I don’t wanna move”, I moaned, and probably cried a little. “I can’t, I CAN”T” I whined, feeling a little pathetic, but with Mitchell’s help I found the energy to do it after another contraction.

I am SO glad he encouraged me to get out. I opened the door, squinting in the bright morning light, made my way across the hall to the bed amidst all the gently smiling people, and crawled onto it. The baby was on my perineum after a push.

I was on my knees with my chest and face on the bed. I felt like I had to thrust my bum into the air as high as possible to open my bones and get the baby’s head out. “Oh, God, PLEASE let it come out, it HAS to come out!” I chanted. Normally, pushing out a baby is not so intense for me in terms of sensation, but every labour is different. And boy, was this different. I wanted to get the baby out, yet I really didn't want to push because it hurt. But if felt more uncomfortable to not push. So I did. I heard Isabelle telling Mitchell that the baby would go between my legs and under my chest as it birthed. Here I have to pause to mention how amazing it is to be trusted. Nobody assumed I needed to be saved. Nobody even assumed that the baby had to be delivered. A picture is worth more than a thousand words…I have a photo of Isabelle’s student about to touch me to tell me that I may want to get off my chest by raising myself onto my hands so I could gather up the baby when it came, and Isabelle’s hand is on hers, stopping her from disturbing me. She had told me a couple of days before that I was a woman who owned her labour, and her faith in me was unwavering.

Mitchell and Isabelle were behind me. The baby’s head came out and it seemed like I waited forever for the shoulders to come out, though it wasn't like that. My first 2 babies were “caught”, and I guess the shoulders encouraged to emerge. My third came out totally painlessly in her water bag, nearly all of her in one contraction. This kid waited for a contraction while his shoulders aligned themselves in my bones before deciding to come out (posterior shoulder first, which is often the case in this position.) “Do you see the shoulders, PLEASE tell me the shoulders are coming out, PLEASE get it OUT!”

I had never in my life felt so desperate to eject a child from my body. He felt so big. I heard Sharon’s lovely voice crooning to me, “Honey, it's coming, so soon, it's coming,” Her words poured over me like warm gentle rain. I will never forget Sarah, who was sitting very protectively in front of me (she is a genius at knowing where to be...she usually gives space, but in this case knew intuitively I needed someone near)...I looked up into her eyes, and probably with a very forlorn expression said, “I feel like I have a watermelon in my ass.” “Yeah,” she said with a look of great sympathy. It was perfect. I looked down and behind me (imagine being on hands and knees and looking between your legs) and I saw Sarah’s hand (coming from in front of me), Isabelle’s hand, and Mitchell’s hand.. not on the baby, but just underneath him so he wouldn’t fall if he squirted out fast. I was the very first to touch my baby's head (there's a great photo of this). Isabelle’s hands touched him with the gentlest, most tender of fingertips, guiding him so he wouldn't rocket out.

Suddenly, I noticed in my endorphin haze that there was my baby hanging part way out of me. I snapped into myself. I bent my left leg so my foot was flat on the bed, reached down, and caught the baby myself. Sharon captured the moment with a photo. The cord went up between his legs so I couldn’t see his sex. I moved it aside and announced, “It’s a BOY!” I scooped my little boy into my arms at 7:42 am and turned around to face everyone. He was just fine. He didn’t breathe immediately and was a little floppy, but he was right there. Apparently I said, “Don’t worry, ALL my boys take a little while to start up,” as if I had around 10 sons. I had no tearing and hardly bled.

My sweet Finn latched onto my breast well and was admired quietly by all. Isabelle went to get Big Sister Kayleigh from her room (she had slept through it all…our air conditioner is loud). After the placenta came out (even that was intense to birth, which was interesting), Isabelle covered me up and Kayleigh came in to see her new brother. She was absolutely beaming. I’ve never seen a prouder sister. Finn was still attached to his cord, and Daddy cut it after awhile. After we bonded as a family undisturbed for a long while, the others making us food, Finn received his newborn exam, as gently as you could wish. The little guy weighed 8lbs 3 ounces, which is quite a bit bigger than my other kids were. I have this incredible photo of Finn lying on his tummy naked on the bed with about five female hands on him, infusing him with love. Ah, if only he could remember that moment! Kayleigh put on his diaper and later on the sleeper that all of the kids wore as their first outfit, and kept saying, “oh, he’s so perfect!”

My elder son Misha had slept over at his friends' house down the street. His friends were three little boys, all brothers close in age. When we called to tell him he had a baby brother, in about 2 minutes there were four little boy faces peeking around the corner of the door, with huge smiles and many missing baby was a precious sight. Oona came home soon after and fell in love with her little brother too.

I cannot imagine a more glorious birth. I am so unbelievably blessed. I keep thinking that so many women would have ended up being induced had their waters broken like mine had. It was very important for me to do what I was guided to do intuitively during labour, and I received that respect and support completely. When birth is viewed as a normal event, the energy from that healthy observation contributes to the health of a birth so much more of the time. But as a doula, I know there are no guarantees of anything, no matter what we do...basically, I am very very lucky. My midwife's role was to be the wise mama in the room, and to use her expertise only if it was needed. I trusted her many years of knowledge and experience to make clinical decisions for me if necessary, leaving me free to not have to worry about anything. No worry normally means better flow of hormones and mechanics. Feeling undisturbed AND having someone being quietly clinically vigilant is for me the recipe for a potentially amazing birth.

I did not receive vaginal exams, and I was not “delivered”. I fully believe one of the reasons so many people "need" interventions during normal births is because birth is seen as a medical event and it’s feared, the stressful environment contributing to the woman having challenges accessing her most primal self. Birth is hard enough without having to labour with interruptions and naysaying. This is why I attend hospital births, to be the one to hold the space of birth as normal and be the love in the room. Love in the room is crucial, and I am happy to say Finn was born into an ocean of it. And had his birth NOT gone normally, we would have gone to the hospital taking our good energy with us, my troupe lending their love and support throughout whatever intervention was necessary for our wellbeing.

Another thing I do to set the tone for a good birth is to honour myself when I’m pregnant and allow others to honour me. I asked my friends to give me a Blessingway ceremony, which I had with my third child as well. We sang songs, everyone presented me with a power object to give me strength for the birth, and we all wore turquoise yarn around our wrists for the rest of the pregnancy, signifying our connection as women through birth. (I have a hilarious memory of Sharon and Sarah holding their wrists out to me after Finn was born saying, “Free us from these! They’re starting to wear us instead of us wearing them!” My friend Brigitte organized a meal chain for me, so I was fed and visited every day for 2 weeks by friends and students! My family was grateful for that, as it’s very hard to get enough to eat when you’re breastfeeding and taking care of children. The food was all nutritious and really delicious!

Finn is a wondrous child, full of curiosity...a dreamer. You can see his sensitivity in his big greenish-grey eyes. He is much loved by his sister Kayleigh, his brother Misha, and his sister Oona. Finn means “bright one” and “beautiful”, which is appropriate, because he brought the sun along with him the day he came. Finn is also the name of a legendary Irish warrior who was, as the myth has it, raised by a Druidess and a female warrior. He was taught magical and healing skills, and guided his followers to choose the high road when making decisions. We only found out about a year ago, after reading a story in a book of feminist fairy tales, that in Irish mythology Finn was married to Oona, Queen of the Fairies. It is amazing how a child's name will fall into place if you give it a chance, and becomes rich in meaning for the family who blesses them with it.

Friday, June 18, 2010

Doula Training for Nurses

I am so very excited. An amazing nurse who works at a hospital I do a lot of doula gigs at used to be a doula student of mine. We have been discussing my giving a doula training to obstetric nurses for years. Finally, it seems to be about to happen. The hospital is financially swamped, as is often the case in Canada, and the training is not in the budget. But I don't care. I'm doing it for free. To have the opportunity to show new OB nurses a different paradigm of birth, and to provide them with some tools to help them feel comfortable with natural labour and capable of supporting it is just too important to make money a concern.

First the nurses, then hopefully soon the med students and residents. I had a really sweet resident the other day try so hard to make my client happy. The resident wanted my client to have the birth of her dreams, but was so worried about her being disappointed, she told her that her birth would not be natural, that it would be long, that it would require an epidural, etc, and that whatever information she was getting contrary to what she was saying (from me, I guess she meant, meaning I was telling her patient natural birth was indeed possible and reasonable to hope for) was suspect. The resident explained that in her medical experience, and in her friends' experience, this was what would more closely match reality. And I understand her intentions, I truly do. But tension and lack of hope don't lend well to an efficient labour. Nor, perhaps, was she aware of the fact that continual emotional support throughout labour can be a powerful aid.

I had worked with this resident before at an extremely long birth in which the mother refused much of the recommended medical intervention and she sadly ended up with a C-section at the end (though not because of refusing intervention, as far as I know). Perhaps this resident believed I put that other woman up to those choices (as is often believed of doulas) and was concerned I was misleading her patient. I don't know for sure. I do know her heart was in the right place, and she was doing her best to protect her patient's interest.

I reassured my client that truly, nobody could be sure of how long her labour would be, and to just take it one contraction at a time. From the time contractions got strong enough to breathe through until birth took only 2 hours. No epidural. Labour begin in earnest as soon as the resident went off call and my client was introduced to the new doctor on call who is always a lovely, positive, supportive presence. Instead of feeling defensive of her desires, my client visibly relaxed and felt like she could trust. Coincidence? Perhaps. But there is a LOT to be said about a gentle, supportive environment making the cervix that much more yielding. As Ina May says, it is a sphincter, after all. If you are trying to go to the bathroom, someone telling you you'll need all kinds of interventions and medications you don't want in case you end up being constipated will probably make the anal sphincter a little shy, perhaps even creating a self fulfilling prophesy. But say, "okay, you go do your thing..your body is well designed to do this..we won't bother you unless there's a need," well, then you may just go with more confidence and comfort. Sorry for the poo analogy, but there you go.

Obviously, birth it too complex to make it as black and white as that, but keeping the birth environment more nourishing than frightening is never a bad thing.

Monday, June 14, 2010

Post Partum Doulas

In a world where the goal of SuperMom reigns supreme, tender new mothers are often left feeling overwhelmed by the expectations they have of themselves. Women often feel if they are not actively managing their post baby weight, contributing to the family financially, keeping a clean orderly home, creating meals, tending to all the physical and emotional needs of all family members, being an attentive friend with a social life, enjoying sexual relations with her partner, succeeding at having her baby trained to sleep most of the night, and with a wealth of energy to complete even some of these tasks immediately postpartum, they are not succeeding as the mothers they hoped they'd be.

The reality looks more like this: a new mama is TIRED. Breastfeeding sometimes has a few glitches that take a little while to work out. She is often left feeling quite tender physically and emotionally after the birth experience. Just getting enough to eat and finding the time to nap to make up for those all night nursing marathons are challenges. The reality sets in after a few days home with Baby that she can either shower OR do the dishes in a day....probably not both. For a woman used to being a multi-tasking, high-achieving dynamo, feeling exhausted, tearful, confused, spit-up stained and leaky-breasted can be quite a shock, no matter what all the books say.

In days of old, we used to live tribally or in close contact with extended family. The home and hearth would be tended to by other members of the family community, and new mothers would be able to focus on healing after birth. Most importantly, they would have ample time to fall in love with and bond with their new babies, receiving experienced, wise guidance from other women in the tribe about breastfeeding and baby care. The new mother would grow solidly into her role without being overwhelmed by needs beyond hers and her baby's, and her confidence would blossom in the light of the loving support of her elders. In some traditional cultures, mothers are sequestered for about 40 days after birth skin to skin with their babies, receiving daily massages and being fed special foods prepared by other women. Contrast this image to our expectations of SuperMom, and we can begin to understand why the postpartum experience is often feared, and high rates of depression reported.

I would like to introduce you to the important, beautiful work of the postpartum doula. A postpartum doula is a woman who is experienced in supporting mothers in the days and weeks following the birth of a baby. It is a role which is very simple in its intent: to ensure a new mother has what she needs to feel good about motherhood, and to help build confidence in her mothering skills. How does the postpartum doula achieve this? By giving Mom freedom to focus on bonding with her baby and family. To achieve this goal, a postpartum doula's skills are many and varied. She provides knowledgeable breastfeeding support, usually encouraging breastfeeding on demand and helping with basic breastfeeding challenges. She answers general baby care questions. Nutritional support is provided by doing some cooking of wholesome meals and snacks for the family. Organizing and light cleaning can help take some of the strain off Mom so she has an orderly environment within which to hang out with her baby. The postpartum doula can integrate siblings into sharing in the care of the newborn, and she can care for them while Mom naps with Baby.

The mother's partner and other adult family members, such as grandmas and aunties, greatly benefit from a postpartum doula's care as well. They learn, through the doula's example, how to confidently physically and emotionally support the mother's unique needs. They learn evidence based information about breastfeeding and baby care, and also get time to rest and bond with Baby when other basic needs are met. Very often, the other parent is also overwhelmed by the needs of a freshly birthed mother and baby. As sleep deprived new dads/moms, they are often still expected to provide financially, do some of the household tasks and cooking, care for other children, and weather the ups and downs of the emotional landscape of new parenthood. A postpartum doula ensures partners also feel cared for, which allows them more time and energy just to relax with their partner and forge their own relationship with Baby.

A postpartum doula nurtures the new parents with her loving, wise presence. While she may bring food, wear the baby in a carrier or sling, and do some laundry while the parents nap, provide breastfeeding support, gently guide visitors to limit their time when she notices Mom is getting tired, and help parents sort out what information is good for them and what isn't, the postpartum doula is primarily someone who listens. She can hear the deeper concerns behind questions, and provide a non-judgemental space within which parents can process their experience. She helps sort out feelings surrounding a difficult birth experience. She reassures the emotional ups and downs are normal, and can help to guide parents to appropriate resources when things veer outside of that range. She is a wealth of resourceful information, able to help the couple choose products that are appropriate for their lifestyles, help them find parenting groups to alleviate the sense of isolation new parents sometimes experience, and can guide them to a myriad of professional resources.

It is important to note that a pospartum doula is not a Baby nurse. A doula cannot “diagnose” or “treat” anything, nor provide any medical advice about a mother's or baby's health. In her experience, however, she can gage when something is a concern, and guide the parents to the proper resources to get things checked out. She can, however, use safe, holistic remedies to help with the basic challenges of breatfeeding and postpartum recovery, such as recommend warm compresses and cabbage leaves for engorged breasts, sitz baths for perineal tears, or massage for “new parent neck”.

Millie Tresierra, Senior Postpartum Doula of MotherWit Doula Care in Montreal, has been a parent/baby supporter for many years. She says, “Rest and nutrition are the two vehicles that will carry Mom and Baby through the first few months together. Everything else will fall into place around these two things.” Her job is to ensure the integrity of these vehicles, and says sometimes she literally tucks the whole family into bed for a few hours while she tidies, encouraging them that emails and phone calls to enthusiastic family and friends can wait. She likens her doula work to holding a little boat (the family unit) tenderly in her hands, supporting it as it learns to navigate the unpredictable waters. Little by little, she releases her hands until that boat learns how to weather the changes in the waters with confidence, and is able to float all on its own.

Typically, Millie meets couples before the birth of the baby to learn what is important to them. What do they like to eat? What makes them feel rested? What are their parenting ideas? What challenges may they have with visitors and unsolicited advice from well meaning friends? What are their fears and concerns? She outlines a schedule that will suit the couple, and then she'll wait for their phone call informing her that the baby or, in the cases of multiples, the babies are born and that it's time for her to get to work and settle the parents into their new and exciting journey.

If a mom admits, “You know, I wouldn't tell this to just anyone, but all my partner and I want to do is sit here and stare at our baby for hours and block the rest of the world out for awhile. Is this normal?” you will most likely hear a postpartum doula respond, “Honey, that is music to my ears.”

Thursday, June 3, 2010

Patient Interest or Witch Hunt?

I had a lovely birth at St. Mary's Hospital early this morning. This baby was truly a miracle in many senses of the word, and it was an amazing honour to support such a powerful, triumphant experience. To know I am a positive part of this precious memory of birth is the deep reward for being a doula.

After the baby arrived safely, the nurse, whom everyone enjoyed as a strong, supportive, incredibly experienced presence, asked me to leave my name at the nurse's desk. I admit it was about 2:30am and my faculties of information retention may not have been at their best, but what I understood was that people who were coming into St. Mary's as doulas needed to register their names. This was news to me. It is true that St. Mary's is not the hospital I work most frequently at, perhaps only attending 10 births a year or so there, but I had not heard of this request before, neither personally nor from my doula colleagues.

I jokingly asked the nurse if I was about to be blacklisted, or if alarms and whistles would go off if I walked into Saint. Mary's again. She said they had a new policy to know who doulas were, because they were no longer allowing "medical management" of birth to be conducted by doulas. I said, "But doulas aren't qualified or allowed to manage anything medically!" Her expression was kind, but made it clear that the phenomenon of doulas behaving badly was alive and well at her place of work.

On the one hand, I most certainly do agree that medical staff should not have to feel medically challenged by a person who is supposed to be providing emotional support and comfort measures for their clients. This is not safe for anyone. I feel very badly for the staff who work extremely hard, have protocols that are part of their job description to follow, have the weight of immense responsibility for the well being of a mother and child on their shoulders, then have to deal with a naysayer in the room whose modes of advocacy are combative, and therefore unwise. If a doula's attitude is negative towards the staff, breeding mistrust in her clients for these caregivers, leading them towards choices based on her personal agenda rather than helping them make informed decisions in light of what the staff deems medically necessary for their care, then makes sense the staff would want to know about this person and set limits on behaviours that interfere with their responsibilities.

But on the other hand....

My name was taken down not on any official form that would reflect this was an established hospital policy, but on a scrap of paper. No phone number, email address, feedback, nothing. Just my name on a little square of paper. Now I wonder what will happen to my name. Will I be Googled? Will they talk about me in the nurse's station? Will they grill my clients on their level of satisfaction with my services? Will they pick through all my behaviours that were annoying to them, blow them up into monstrous proportions, and then put me on the black list so that when I next walk through the doors of St. Mary's I will be met with the stink eye by everyone? I have to say, I am concerned.

Of course, my first thought was to go over my behaviour. It is always very important as a doula to constantly review where we can improve. My clients seemed to be very happy with my services, as I helped them to have the un-epiduraled birth they were dreaming of. So how did I do this?

1) My client had to have an I.V. for medical reasons, so I asked the nurse (not the same one who took my name) if a saline lock could be put in so she could walk around. Remember, I spend a lot of time with my clients prenatally, and get to know what would help them, given their personalities and concerns, cope with the challenges of labour. There was no doubt this lady needed to move a lot of energy by walking. The nurse said this would be no problem. It wasn't offered as an option, but upon my asking, it was kindly given. So walk my client did...with more energy that I had, not to mention a few trips up and down stairs, which would have been impossible with an I.V. pole. The monitoring devices were wireless, which allowed for free movement, so it only made sense that not having to march around with a heavy I.V. pole if not medically necessary at that time would make my client more comfortable. St. Mary's is a hospital which embraces the Baby Friendly Initiative, and I figure empowered birth must be an aspect of that initiative, given there are textbooks on the subject of the impact of unnecessary medical interventions on breastfeeding.

2)My client wanted to avoid labour stimulation. Due to existing circumstances, getting labour going was an important goal, so I used lots of acupressure and aromatherapy, which really seemed to help pick up contractions. Eventually, some synthetic oxytocin was ordered by her doctor, and I in no way got in the way of the staff doing what they had to do in that regard. That is beyond my scope of practice. The stimulation was absolutely minimal, and resulted in an un-epiduraled, beautiful birth.

3)My client wanted to be free to be in whatever position she wanted, but when it came time to push, her doctor was not immediately available, and it looked like the nurse would be catching the baby. She put my client into the traditional position, and as my client didn't argue about it, I didn't feel like saying, "Hey, you said you wanted to be in another position...are you sure you want to be on your back?" would enhance the situation. I felt it was important for the nurse to be comfortable with what she was doing, as she was put in the position to be responsible for this situation. My instinct was just to be silent and to trust my client would speak up herself if the position was not good for her.

4) I could tell my client was NOT liking the yelling at her to make no noise during pushing. She was vocalizing powerfully, and her baby was moving down. In fact, the baby moved down and out in 12 minutes, most of the time with her mom bellowing. I never direct pushing unless it's asked for by my client, or she is very scared to go into that downward sensation and a little encouragement to bear down to push some of the tension away would be helpful, or it is made known the baby truly needs to come out quickly and focused pushing is necessary. The reasons I try to remain quiet are 1) There are enough frighteningly loud voices in the room contributing to the Purple Pushing Party. 2)With a baby coming down that straightforwardly, it makes little sense to me to make a mom feel criticized for how her body is naturally and spontaneously expelling her baby. I have personal experience of pushing with no direction. I know if she were birthing unassisted accidentally somewhere, nobody would tell her when or how to push. It would just happen, and the VAST majority of the time Baby would simply emerge, Mom yelling or not yelling. I don't buy the argument that a woman will get more exhausted by the second stage being longer if she is doing what comes naturally as opposed to making it fast by expending eyeball popping effort. Yes, we know on average purple pushing makes the baby come 13 minutes faster, but evidence suggests to me, granted this being merely anecdotal evidence, as I'm the one who follows up with the mom postpartum at home, that she's in better shape when, if possible, she directs her own pushing.

Now it's important to note that while this is my personal opinion, I didn't state it out loud. There's no room for naysaying in a birth or ego centred battling over a client's body. I didn't request anyone stop directing. At some point my client looked at me at and indicated she was not enjoying being yelled at, that her vocalizations felt good to her, and I just winked at her and whispered that she was doing beautifully and that her wonderful efforts were making us see the baby already. Those words made her realize she was not actually doing anything wrong without criticizing anyone else in the room.

5)My client was interested in the baby latching on by herself by doing the breast crawl. St. Mary's is very supportive of constant skin to skin contact after birth, and it was a lovely, gentle environment for this new being in the world. Sadly, as the breast crawl often takes more than the hour or so the mother is left in the birthing room to recover before being transferred to postpartum, it is often unrealistic to be allowed to wait this amount of time. This sort of diminishes the Baby Friendly aspect a little, as the W.H.O. seems to very much support infant initiated latch. So if there isn't enough time to do it, then this crawl must be interrupted so the baby can at least get a suckle in before they have to be transported to postpartum. Not ideal, but as the beds are being waited for by labouring mothers in the hall a lot of time, C'est la vie. Baby was very alert and by being placed closer to the breast, she found it and latched on her own anyway, in a biologically nurturing position.

6)My client did not want drops in the baby's eyes until after feeding was initiated. The nurse was about to put them in the eyes and I asked what the window of time was, as every hospital seems to have a different policy on this. The nurse said it has to be done right away when there is GBS. I didn't argue, as this was again not a huge issue to begin discussing, but I have had doctors tell me the drops don't affect GBS, that they are only really for possible STIs. It is difficult to know what to do when the information I receive from various sources is often conflicting, and as the parents at the time weren't too worried about it, I let it go. Parents in the end want to remember peaceful contact with their newborn, not battling opinions.

7) In postpartum, when the baby was about to get the vitamin K shot, I asked if she could be at the breast while she was receiving it. This was not offered as an option, but was happily provided upon asking. The parents were very glad for this arrangement, as suckling releases endorphins and calms the newborn, thus reducing some of the pain of the injection.

All this is to say is that I feel I walked the line appropriately of advocating for my clients' wishes in a positive, friendly way, and not getting in the way of staff members trying to do their jobs.

Taking down my name on a piece of scrap paper makes me feel scrutinized. I am not worried that I did anything to endanger my client's or her baby's health, but what does worry me are the implications of this "policy".

All of the staff I worked with were kind and respectful of my clients' experience to the best of their knowledge and ability. They were kind and respectful of me too. But what if a doula coming into St. Mary's is just doing her job the same way, but for some reason her personality or approach rubs a nurse the wrong way that day, even if she's not actually doing anything inappropriate? What if a nurse is particularly sensitive to perceiving criticism when a doula is supporting her client a certain way and the client is more responsive to the doula's support than the nurse's, and the nurse gets upset? What if the staff believes the requests and "rebellion" of the couple are being generated by the doula herself? Remember, just because a patient is challenging doesn't mean the doula should be made scapegoat. If a client squats on the floor and starts birthing, or pulls out her IV, or refuses to get on her back, it doesn't mean we've guided her to do so.

I don't believe for a second many of us are as bad as we're made out to be as a group. Yes, there are undeniably a few bad bananas in every bunch, as there are in hospitals. This doesn't mean each doula should be demonized for every little inconvenience that comes up for the staff, or be judged unfairly because the last doula who was at the hospital happened to be a nightmare and everyone's still reeling from that experience.

The bottom line is the role of doula is bequeathed to us by the parents themselves. They understand the hospital system can be big, unfamiliar, overwhelming, and with unpredictable service. We don't come storming in bringing our clients with us to prove a point. We are there because your patients hired us privately to be there, knowing that in labour they may be too vulnerable, occupied, or unaware of what their options are to achieve their greatest comfort. Yes, that is a criticism of your system. But you know it yourselves. Don't blame the doula and project onto us your judgement that we embody this criticism, are there to make your lives miserable, and to make our clients our own personal political projects. A good doula wants to bridge the gap between the solid clinical care and technology you provide, and continuous one on one support and advocacy, which, sorry to say, means we will ask questions in order to facilitate the best experience we can for our clients. I will not do this in a way to make you feel that your patients are endangered. I respect your knowledge and experience. I will honour your medical choices, but I will at times, if it is appropriate to the situation of my client, question the evidence of some traditions and statements, and request things that may not always be the most convenient for you, like saline locks and intermittent monitoring while a client sits on a ball instead of lies on a bed. You may notice me being very different from one client to another. This is because we advocate the CLIENT'S wishes, not mine, and all clients have different needs and wishes.

My career and livelihood depends upon my being allowed into the hospital system. This is not just some little hobby of mine. I have spent almost 19 years developing myself and my skill set to be a doula to the best of my ability. To become blacklisted because someone's ego was bruised one day, or because someone misinterpreted my question for my client's sake as a personal attack, or if my client locked herself in the bathroom and gave birth without my having any clue she was going to do that, crosses the line between claiming safety for patients, and a blatant witch hunt.

Doulas, I think it is really important when you go to St. Mary's Hospital to ask to officially see this policy on paper, and to have everything explained to you before you give your name. I was very busy, and didn't manage to do this. My sense and fear is that even if you work within the scope of doula practice, doing your best to be as nice to everyone as possible, you might be misinterpreted, someone might get mad at you, and poof, there goes your ability to work at St. Mary's. Not to condemn a hospital staff as a whole, but there might be some people who will dislike you immediately simply because you ARE a doula, and will interpret every question, word, and action as a criticism or threat. I have seen this. It is certainly not the norm, as I find the vast majority of people give us the benefit of the doubt if they don't know us. But what if you get unlucky? I want this policy to be extremely clear, out in the open, publicized, doulas made aware of it immediately when they arrive, AND I want some assurance that our practices are protected from those who are unequivocally anti-doula. St. Mary's wants to be protected from doulas who are anti-hospital, and I understand this, but it needs to be a two way street. Whether or not our presence is appreciated by hospital staff, our popularity still grows, good birth outcome stats still rise with our presence, parents still love us, so, friends, we ain't going anywhere. My spidey senses tell me clarity and forthrightness about this new policy needs to happen before gradually all of us doulas who work tirelessly to create a legacy of gentle, lovely, humane hospital birth are, so to speak, burned at the stake.