Friday, February 11, 2011

Positions in Labour

When I meet people who are interested in working with me as a doula or childbirth educator, one of their burning questions is: "Are you going to teach me about positions to use in labour to make me more comfortable?"

While I may do the briefest of overviews to show what many women enjoy doing positionally with their contractions, asking them and their partners to try them out so they can feel comfortable knowing what they are doing is totally normal once they're in labour, positions for comfort is actually something I don't focus on a lot. I tend to find most women know what to do in normal, ummedicated, physiological labour to make their contractions more efficient and comfortable. If we provide fancy charts of positions that are helpful to birthing women, it assumes they will be using their intellect during labour to mentally bring up the image of the "menu" of positions (or check their notes while actually in labour), and select which might work for their particular scenario. While this may help in early labour (or not, as I tend to recommend the "don't focus on early labour and find something to distract yourself with" approach rather than the "focus on the early sensations with all kinds of positioning and massage so you're at a loss as to what to use to help when things really get cooking" approach), the kinds of contractions that have you drifting away on an endorphin cloud to lala land are simply not conducive to the mental gymnastics of cross referencing.

I have actually not seen a labouring woman with back pain NOT lean over or go on her hands and knees to take that desperate pressure off her sacrum. I often see women who are being monitored while lying on a bed rip off the transducers and stand up because they simply cannot lie there any longer. They can't tell you why, they just know they cannot bear that position anymore. Their bodies are guiding them intuitively, their babies whispering from the inside, "Mama, I need some more space...move this way."

I have had women yell in transition, "Tell me what to do! What do I do?!" and I'll make a suggestion, but inevitably they do what they want. I remember a woman asking her midwife what to do and the midwife suggested she sit on the toilet. It's a great suggestion...the opening of the legs, the safety of the toilet, the squatting position putting pressure of the baby's head on the stretchy cervix, helping it to open perhaps more quickly. There's no need to explain all of that to the labouring mom , as it's too much information for her to process. All she wants is some direction on which to anchor her hopes that this will all be over soon. Despite the midwife's simple suggestion, the mom just stood over the toilet. All she wanted to do was stand, so finally after being asked several times what she should do, the midwife validated that clearly what this woman wanted to do was stand, and to trust that. When she started grasping and pulling down on the shower rod, we guided her out of the bath (where she was standing) so she could grab onto the trapeze bar provided for that purpose. She birthed beautifully hanging from the bar. That would have happened whether she had been educated about positions in advance or not.

Labouring mothers often do some strange things to comfort themselves in labour, and it's all good. I've seen women lie down on the bare hospital floor because it felt cool, stand up on a chair because the floor felt too hard, or walk like an elephant on all fours swaying to and fro with their heads. All a mom needs to know is that if it feels good, she can go for it.

Where positioning education comes in very handy is when the mother has an epidural. Because many of her body instincts are numbed by the medications and positioning of the baby can become misaligned with the pelvic structure, suggestions of position changes help a lot. And because the mother is capable with the reduction or absense of pain and endorphins to draw upon her intellectual capacities, a check list she's learned in advance of positions to increase labour's efficacy can be extremely useful if she doesn't have anyone around to guide her with this.

When labour is NOT going normally and clearly the baby needs to do some shifting to create a better fit with Mom's pelvis, positioning can be extremely helpful. I had a mom once whose back was so sore and stiff from a long hard labour that she couldn't sit down. She wanted to, but the aching prevented her from acting out her intuition. Her husband and I tried to guide her to sit on the toilet, but she just couldn't bend her knees. Her poor back was raw from all our rubbing. Her poor bum muscles were so tight from all the pain, so my instinct was to grab them and shake them out. I did this for a good minute, just jiggling those bum cheeks. We were all giggling a little. Finally the mom sat down, and things got moving immediately. She ran to the bed, got on all fours, and was found to be fully dilated. Again, we could teach all that in childbirth ed, but really, when in the throes of labour, without some skilled direction, she and her stressed out partner probably won't think about all the possibilities or receive support. This is why good childbirth education AND good doula support create better outcomes than just education.

Positions for rest are something I like to talk about. Sometimes moms get really tired, but cannot stay in a position during contractions that they really like between them. So knowing how to rest and contract in one position for a bit while she regains her energy is useful. I like using a yoga ball and edge of a bed or counter to lean over on for resting and contracting, or hanging out in the bath. It's important that the skill of how to rest and chill out in labour is as important as riding the waves of contractions.

Another area in which discussiong positions is useful is when it comes to the second stage of labour. I love to watch people's faces as I demonstrate what a normal labouring woman often loves to do when that fetal ejection reflex kicks in...butt juts outward, arms reach up to grasp, torso leans way forward. I gently and slowly tip myself backwards without moving any limbs, just letting my hands grasp my knees, and it really hits home how, when you adopt the stranded beetle position, a woman is asked to do the EXACT opposite in most OB assisted births of what Nature asks, effectively mobilizing the sacrum (which dearly wants to be able to stretch and yield to the babe's extending head), perhaps necessitating circus style pushing to compensate for the smaller space created in the pelvis, and potentially wreaking all kinds of nasty havoc. Telling women that there is a good possibility of their not feeling great being on their backs while pushing (as many don't know this is not the real "way" the body likes to deliver babies), and that their instincts to do otherwise are spot on regardless of what they're directed, helps them to know they're not "bad" patients or somehow abnormal. And it's also helpful for them to know that there is no black and white, and that if they do happen to feel good on their backs, then this is absolutely fine too. Just because it may not be an ideal position for some, it may certainly be for others. I have seen women whose babies are exiting with great speed (myself included) throw themselves spontaneously on their backs. Perhaps this is how we are intuively guided to slow things down a little.

It is important to remember that birth is not intellectual from the birthing woman's point of view. The more charts and diagrams a woman has to look at and follow, the more she gets caught in wondering, "okay at what point do I do this, what sensation necessitates this position, etc." This is exactly where we do NOT want labouring ladies to their heads worrying about what is "right". If they seem as happy as they can be in super active labour and things are going well, then it's right. The most useful tools in childbirth education are not the fancy tricks that are learned involving balls and positions, but the practice of relaxation, release of tension through whatever means the mother prefers, and the ability to stay with the sensations confidently as opposed to reacting to them with fear.

Tuesday, February 8, 2011

A Guide to Holding Birth Trauma

Scary things can happen in birth sometimes. It's not something we like to think about, but the fear of emergencies in birth is something that lurks in the corners of the minds of pregnant women and their caregivers alike.

As doulas, occasionally we are front row centre witnesses for someones trauma. It can feel powerless watching those scary things unfold. We are often grasping at straws in our minds wondering, "What do I do? How can I help fix this?" Well, sometimes we can't. As much as we try to prevent birth trauma by guiding people to empowered choices and as much as we hate for bad things to happen to the couples in our care, the unexpected can occur. We can end up feeling very powerless when an emergency takes place, and it's crucial to know how to anchor ourselves in the eye of the hurricane so as to create the optimal space for healing to begin as soon as possible.

While trauma is occurring:

1) Acknowledge it. We need to look those parents deeply in the eyes, take a breath, and in our own gentle, loving way say, "Yeah. Here we are. That scary place nobody ever wants to go. Breathe, and hold on.". Trying to "make it pretty" when the proverbial poop is hitting the fan, minimizies the experience and only leads to dissociation.

2) Stay present. Breaking down emotionally, getting caught up in those bubbles of fear and drama, and freezing up is not an option. You cannot "check out". You need to open your heart up, waaaayyy up, stay anchored within the chaos, and stay there strongly with your clients. Be totally present, surrounding them with as much love and calm coming out of that open heart space as possible. It may sound flaky, but the emotional tone we set can have the power to keep others calm. As doulas are very much "space holders", what we energetically broadcast into the room can influence how the parents and caregivers respond to the trauma.

3) Reassure when possible. If a woman has to go through a tough obstetric procedure, while we can't make it rosy, we can definitely let her and her partner know all the positive aspects of what is happening, like "You are doing GREAT!", "We can see your baby now, hang on!", "This is the hardest part and it's almost finished." If Baby is an issue, repeating the positive things you hear the caregivers saying can be helpful to parents, such as, "They say your baby's heart rate sounds great." or "Her breathing has improved a lot in the last minute." A blue floppy baby is all a parent will see, and if it is appropriate, letting them know the good stuff that is going on with their newborn while the caregivers are busy focusing on their tiny patient can help promote calm. Often, parents will not receive this information, and their terror of the unknown could otherwise exacerbate their sense of trauma surrounding the memory of their child's first moments of life. Being informed and reassured whenever possible is comforting to parents. The look on the faces of new parents when nobody is actually telling them the baby is breathing with a good heart rate is enough to ensure you as a doula are on top of this.

4) Be loving. Touch the mom, speak to her lovingly, stroke her hair, coo to her. Be loving to her partner. This helps to promote oxytocin and reduce too much adrenaline response. Doing whatever you can to keep that mother/baby hormonal connection intact, even when the baby needs to make a fast birth exit or has just had a difficult passage and is not able to be in the room with her, may help improve her future memory of her birth experience.

5) Trust. Give caregivers ample room and support in their important job of dealing with a medical emergency. Trusting doesn't create the outcome we want, but staying connected to the trust whenever possible that everyone is doing their best, promotes calm, often helping the best care come about. As doulas, our spiritual beliefs are definitely something to draw from at this time, if we are so inclined. The idea of trusting that as we hold the space for our clients and everyone else in the room, all of us are also being held by a loving source, even if what's happening is something we can't make sense of, is something many doulas and caregivers seek comfort in. Knowing deeply we have no ultimate control and that our power lies simply in doing the tasks required, being present, and living this moment as fully as possible, no matter what, is often what helps us all to heal more completely when the emergency is over.

Once trauma has occurred and everyone is left picking up the pieces:

6) Beware of magical thinking. I had a sweet, lovely student end up attending several dramatic C-sections for her first mentored births. After the third, she broke down in sobs, asking, "Is it ME?" The doctor present was loving but firm and gave her a great reality check: "Ah, Sweetheart, you feel like you've earned the black crow award because all you've been present for so far is emergencies. We can all feel like this. Really, though, you're not THAT powerful that you can bring on bad outcomes just by your presence." This is a wise and straight to the point wake up call on those days we are stuck in the past traumatic experience, trying to envision what a different outcome might have been had we heroically jumped in to do the impossible to spare a woman from turmoil. Know what to own, know what to let go of as magical thinking. Help your client avoid falling into this trap too.

7) Don't entertain the "why" and "what if" too much beyond getting to the basic physical reasons something may have happened. Spending hours conjecturing "why" is not healthy, and with doulas/caregivers sometimes even arrogant as we try to throw out many hypotheses that will usually only ever remain hypotheses. It soothes our egos to have a tangible reason for those unexplained traumas, but healing isn't about soothing our egos. Sometimes things are just mysteries, and what's done is done. Sure, when there is evidence for something, it can feel good to know actions were completely justified. However, often there are many pieces of the puzzle missing, and will always be missing. An amazingly wise Abenaki Grandmother told me once, "Every time you ask why, Spirit takes a step back. Who says you get to be privy to why something happens the way it does? Instead, ask, 'What is it I can learn from this experience? Spirit will take a step forward.'"

Many clients after trauma will ask if you think the outcome could have been different had they done something else, for example, let's say, birthed vaginally had they avoided the epidural. You cannot possibly answer this question. Gently point out that wallowing in the whys and what ifs are fodder for self flagellation, and not healing. Embracing the experience for whatever it was, good or bad, making meaning of it, and living fully is usually a better choice for healing. This may only come about after a long period of grieving.

8) Debrief with your clients about their experience. Let them pour out their pain without trying to pretty the experience up for them. Don't join the ranks who say, "Well, at least you have a healthy baby." (if the baby is indeed healthy). Women need to feel "allowed" to grieve the loss of the experience they wanted. It's not selfish to have hoped for a lovely birth. It is heartbreaking to have suffered trauma. Grief is totally appropriate. My dear friend says when something has gone badly, "Dude, that sucks." She says it with absolute compassion, and there is comfort in knowing that someone acknowledges that something plainly sucked as opposed to having someone be chirpy and sunshiny when the real emotional landscape is so obviously grey. We want people we care about so much to feel better, but it's not always possible for a while. Sparing someone from authentic feelings and creating dissociation by interjecting niceties is more about our being uncomfortable with their feelings, and it's the same pattern that contributes to such high epidural rates, "Oh, poor dear, you're suffering. I can't stand to see you in pain. Let's just make it go away."

When the whole thing is talked out and there is more emotional space for perspective, connect them to where they were amazing and graceful in dealing with such challenging circumstances. It's not the same as trying to make it pretty. It's honouring the person's role in authentic and powerful living. They may have felt totally "weak" because they cried and couldn't "get on top" of things. Crying and feeling scared is emphatically NOT weakness. Just as the icon of the Zen woman breathing easily and painlessly through her contractions is not an appropriate image of birthing, neither is the stoic stiff upper lip image for someone who is softer and more sensitive.
Deeply honour how a couple moves through the unique emotional terrain of their unique births.

9) Provide resources. If couples need to seek more counseling about birth trauma or reactions of anxiety and/or depression, knowing which professional avenues to send them down is important. Be very aware of your limitations. Doulas are not therapists, and owning all of your client's emotional process is not appropriate, potentially blocking their healing by not sending them to the proper resources. You can always be available for support, but support doesn't mean owning their healing.

10) Doula heal your Self. When you have been traumatized, it is your mandate to deal with it. You cannot bring past trauma to the next birth and be fully present for the clients in your care. Doulas can and most certainly do experience Post Tramatic Stress Syndrome, whether it be from a true birth emergency to witnessing violently harmful and disrespectful behaviour towards a client. Whatever the reason, it is our responsibility to take the time we need to heal. Write it out. Connect with your own spiritual practices. CALL YOUR SISTERS! A community of doulas is the best way to help each other heal. I'm all about doula-ing the doula and without the support I receive from my community, I would most likely be a gibbering mess today. Reach out, talk it out, and embrace the incredible richness of this life of birth attending. Connect, ultimately, with your Love, as this is what grows when we remain present and seek to heal our own wounds. This Love can serve as a light to those healing their own traumas.

Monday, February 7, 2011

MotherWit Birth Doula Training Begins Soon!

I am so excited to be welcoming the new wave of doula students who will be embarking upon this journey with me on February 17th, 18th, 19th, and 20th, and March 17th, 18th, 19th, and 20th.

This is a bit of a new format. Our last training was in the beautiful hills of Morin Heights where we connected to Nature and lived/breathed/ate/slept Birth for six incredibly intense days and nights. This format suits those who cannot leave the city for that long, and who like to take things a little slower, having a month's break to process learnings before moving on to studying how to hold the more challenging aspects of birth and hospital environment. I will still do intensives for any group of doulas who wish anywhere in the world, but the Montreal training will be a more leisurely format this year.

Apprenticeships are wrapping up from the last training...we have established regular case study/doula support nights, the students are well connected, providing support and guidance for each other, creating and nourishing the community of birth healers I have been wishing to see for years. Many are almost finished their training requirements and soon we will have more well prepared doulas out in the world who have been guided and mentored. This is the core of doula work: woman to woman support, birth attendants healing themselves, an ability for doulas to not only know how to help on a factual level, but to intuit, guide, and offer wisdom. I am so deeply proud of my trainees, as they slowly make their transition from apprentices to colleagues, adding their voices, their stories, and their skills to those of the many visionaries we need to bring this birth culture, which has spiraled outwards in its insanity, back to where it belongs...into the hands of the its very root a transitional journey ripe with potential for healing. It is an honour to embrace these women as sisters.

I open my arms to all of you, new MotherWittie novices, and am so glad to have the opportunity to teach you some of the things I know. We are going to have fun, you are going to experience challenge, and you will find healing and growth. Thanks so much for joining us, and I'll see you in a few days!