Friday, April 29, 2011

"Why Don't You Just Take the Epidural?"

Firstly, before anyone decides this is a rant against epidurals, let me explain. I am emphatically NOT anti-epidural. You cannot work in birth for nearly two decades and be anti-epidural. Just because I'm a doula, the very word conjuring up images of bowls of organic granola lovingly moistened by the milk of the goat who lives in my back yard, do not assume I am all about all natural birth all the time. Ultimately, I am about whatever works and women's choices. Just to be clear.

Before exploring some of the questions I've heard people ask in response to the shocking idea of natural birth, let me defend the poor old epidural for a moment. Everyone who has worked in a hospital birthing culture for a reasonable amount of time has seen how an epidural can potentially and sometimes even miraculously restore morale and labour efficiency to a woman who has been labouring hard for a long time with the discouraging news that she is not opening. We all have stories of women who stayed at home for a couple of days with contractions strong enough to make them vocalize loudly. You know, the kind that look like the baby should be coming soon but just isn't, so they decide at their limit to accept an epidural when they find out that the three centimetres dilated cervix their doctors told them they had 2 days before they even went into labour has not budged in the 72 hours of minute long contractions every few minutes they've been having. And then boom, she goes to 10cm in 30 minutes after a break in pain. Could it be there was a real physiological need for the epidural and its benefits of relaxation? Maybe. Could it have been a psychological thing? Perhaps. Could this be a product of our enculturation? Sure, why not? Regardless, it worked, and the baby came vaginally, an epidural being less of a risk and less of an invasive intervention than abdmonial surgery. So let us give credit where it is due and a round of applause to this brilliant invention that can and does help some mothers' births proceed a little more normally sometimes. Sure, most babies would come out given enough time. But in cases like that you might start to ask "at what cost?" Sometimes, one might need to admit that in the the odd case the benefit of an epidural outweighs the risks of a labour continuing the way it is. Sometimes no matter what stops the support team pulls out to help labour progress more normally, from emotional support to comfort measures, to maternal positioning, to bodywork, to homeopathy, to down and dirty emotional/spiritual excavation, our efforts do not magically produce a baby. Nobody is to blame. And you can look for the "whys" and "wherefores" all you want, but in that moment that's not necessarily the healing thing to do. In these cases, sometimes the epidural is the most compassionate and effective healing tool.

It is also important to emphasize that doulas are not anti-intervention, they are pro choice. If a woman is truly and fully informed of the risks and the benefits of routine epidural (those risks can be found within seconds on the internet for those not in the know) yet in spite of that knowledge still claims she will want an epidural because she knows herself and her relationship to pain, then it is not our business to judge her. Sometimes getting to the bottom of what is often fear helps her to move through that desire and she ends up birthing perfectly normally. Sometimes not. It is our job to support her with as much love and enthusiasm as someone going for those natural births we tend to like. It is simply not true that a woman will only choose a routine epidural out of ignorance and an unwillingness to let go of a sense of control and propriety. You still grunt, cry, bleed, and poop with an epidural...sometimes for longer than you would without it. Yet even when this is explained, some still want it. I tell women it is totally normal to bellow up a storm while in good labour, that of COURSE it's fine and even desireable to make some noise, as how would you and a baby, if you found yourself accidentally birthing in the forest, keep those blood thirsty carnivores away without your yells scaring the crap out of them? Even with that doula-logic instilled, some still want that epidural. Fair enough. Everyone has their reasons, and everyone deserves to have their decisions understood and respected when it comes to pain relief in labour. I do my best to educate, and if we want to remain in the spirit of true empowerment, we stand by the choices our clients make for their coping methods. Period.

So I just want to take a moment to explore the question, "Why don't you just take the epidural?"

Here are some of the thoughts I've heard people express on the subject.

1) "If there is all this pain relieving technology out there, why wouldn't you just take the epidural?" It is understandable that most people in our western birthing culture cannot understand why on earth a woman would want to go through that pain when they didn't have to. The spirit of this question is usually meant with compassion, an expression of curiosity around the idea of why one would choose to take the pain filled jourey of childbirth as opposed to the much more comfortable one.

This speaks to a fundamental lack of understanding of the benefits of natural childbirth. The pain is not just some inconvenient by-product of the process, it is what helps to conduct the flow of hormones. You contract, you hurt, you get more oxytocin, you hurt even more, and so on. If you're feeling okay and nobody is bugging you, this flow is usually not interrupted and the baby is born. If it is constantly interrupted by routines and a demand on the intellectual as opposed to mammalian part of your brain (like timing contractions, grrr, and strident heart monitoring protocols), things may feel more painful and be less effective. And the opposite can be true in some cases as well. Birth can be fickle and it can not give a crap about what's going on externally. It is too unpredictable to pin down. Contrary to popular belief, I have not seen this pain phenomenon make women automatically turn into crazed evil banshees, lashing out at their partners for ever having impregnated them. That's media education for you. For the most part, if the mother feels safe and well supported, I usually see the oxytocin make them behave very lovinginly and trustingly, and sweetly spoken. Even at 9cm of dilation, the vast majority of women are grasping me tightly, apologizing for possibly having hurt me, murmuring how glad they are I'm there, and I kid you not, I have even been told "I love you" on more numerous occasions than you would believe in such an intensely painful situation.

My neighbour has the mouth of truck driver, God love 'er. Her husband was terrified she would totally alienate the hospital staff when the pain of labour hit and made her start swearing a blue streak. Well, wouldn't you know, labour came, she did it naturally, and all her words were sweet and grateful. Not that labouring women don't let out a few choice curse words here and there...sure they do and that is fantastic. It's good to vent now and then. They get pissed off that the baby's not coming quickly enough or bummed out when someone is not doing what they need them to even though she has told them five times. But that brief annoyance is usually not directed at anybody in the anger you might expect of someone in a lot of pain. Put it this way, I have been hugged 99% more times than smacked while helping someone in labour, so, given the intensity of the sensation (been there, so I know what I'm talking about), you've got to figure the hormones must have some effect on that.

This oxytocin, when the baby and then placenta comes out, is as it's peak. The whole room seems jacked up to the hilt on the stuff. It's beautiful. When the baby arrives, usually most of the pain is gone immediately, relief sets in, and in a couple of days when the body memory fades, women say, "Oh my God, that was AMAZING! I would do that again." It is discombubulating if you're not aware of the beauty and power of natural birth, even when it looks INTENSE. You might think the mother is some kind of masochist given what you've just see her go through. But regardless, they usually do go on and do it naturally again if they've done it before. I have. Four times. In spite of the yelling and feeling like you'll never make it. In spite of sensation that makes you think you will never be able to contain it in one little body. In spite of the exhaustion, shaking, and nausea. In spite of the nine months of pregnancy challenges and discomforts. You most likely choose to do it that way again if it worked out for you before. And hey, even women who have had really tough, intervention filled experiences usually give birth again, many, even though they may have been those ones stuck for days at 3 cm with howler contractions and no progress, go into it the next time with the intent of doing it naturally.

So why do some women choose to do it naturally, whether they are first timers, have had a natural birth before, or have had terrible experiences before? It's not just because of the known health benefits of not messing with this particular blue print Nature has given to us if it's not warranted, but I guess because at the end of a good birthing journey, there's a body knowing, a deep soul intuition, a flash of motherwit if you will, that occurs when a birth has gone normally. It bestows upon your being a sense of rightness. In spite of all the judgements of "you're crazy." It just feels...right. It is what glory feels like. Labour is not something you love while you're doing it most of the time. You love it when it's done. It is at the same time the hardest and the best day of your life. Up and down, ebb and flow, effort and rest, give and take, scream and love.

2) "You wouldn't have root canal without anesthesia, would you? Why on earth would you have a baby without drugs if it hurts that much?"

This analogy bugs me to no end. It's stupid, even though it's asked if YOU'RE stupid. Sorry to those who like to use it. Root canal is a procedure dealing with a pathology. In your mouth. Someone is doing it to you to help you with something in you that is sick, impacted, and potentially rotten. If you want to put the intended nature of that question into its proper context, you should ask, "You wouldn't have a Cesarean without anesthesia, would you? So why would you have a vaginal birth naturally if it hurts so much?" But then you'd sound like a total tool, as the intention of Cesarean is to quickly remove a baby from a mother if one or both of them is in mortal danger (well, that's what it used to be for, anyway); normal vaginal birth is...well, normal, even with the level of pain usually involved.

Women have been birthing for a scabillion years. In fact, you, yes you, would not be here today if you did not come from ancestors who, from the beginning of time, birthed vaginally without epidurals. Even if your great grandmother and mother had a little help, or you were conceived in a petrie dish, it still means that (at least up 'til a couple of generations or so ago) you come from a line that can be drawn back to the dawn of birthing humanity in which they rocked birth old school. Yeah, we may have lost a mom here and there along the way. The benefit of living in the now is that maternal death happens less frequently in developed countries (though with all the stats on the impact of all this surgical birth on maternal health, even that is seeming sketchy). You may have lost a lot of great great great uncles and aunts over time. But you are here. How many births have occured in your ancestral line to get YOU here? Millions? Is this not a testament to the birth giving brilliance of your Grandmothers' bodies? And if you want to use the evolution/big fetal head argument on me, you're barking up the wrong tree. The poor old decrepit female pelvis is probably not to blame for what seems to be more difficult births and all these interventions to save us from the pain and death invading us from all sides. It's probably a combo of fear, enculturation, detachment from our bodies, sitting on our butts all the time, pain management messing with our hormones and muscles, birthing positions that are antithetical to simple mechanics, lack of real emotional support as everyone pays more attention to drama and danger, and a bunch of numerous other things I'll just get too mad about if I start writing about them now. The point of the whole "root canal/childbirth" analogy is that it needs to be put to rest because it is just an insult to one's intelligence and a spitting on the honour of our Grandmothers.

3) "Isn't wanting to give birth naturally just a display of feminine machismo?"

I have sat outside rooms beside a couple of male doctors, with the woman inside the room yelling and keening with her birthing pains, ask me that very question. I am not picking on male doctors, as I have known women to say this too...about other women. This feels even worse to me. Anyway, in these cases, I could sense the doctor was having a hard time not wanting to save the woman from what clearly sounded like abject suffering. The tension from hearing these sounds when there is a perfectly good Epidural Man walking around the hallways administering sweet pain relief can be a lot for many people, medical or otherwise, and they start to wonder as their stress builds, "well, if it really hurts that much, isn't kind of stupid to suffer like that? She can't give birth with all that tension. She's hurting herself and the baby. This is all ego based posturing so everyone can tell her what a hero she is afterwards." I invite those with this belief to reclaim their projections. Part of them is saying, "I want you to end your pain because I can't handle it." Trust me from many years of working with natural birth when I say that the most hard core natural birther will call for help when she has reached her limit. No thoughts of heroism intrude upon a woman who is in truly dysfunctional labour. It is obvious in one's deepest core that something isn't working that great. She stops being all trance-y and stoned with the contractions and the bad kind of adrenaline starts working, and she starts getting more intellectual about things. I myself have been in that space wondering, "hmmmm...I may need to think about plan B". We don't push ourselves to the limit or go about trying to prove a point at all cost. Nobody wants to put their babies or themselves at true risk. We push ourselves to the limit because we're handling it and we're strong, thank you very much.

Let us be clear about one thing. We as a culture use the phrase, "you don't have to be a hero" to women who state their intentions to have a natural birth. What we really mean is "don't be a martyr". A hero shines in beneficence and helps heal our world on various levels. Is it wrong to be a hero, for ourselves, for our babies? Is it wrong to want to create new legacies for our future birthing daughters and to embody the magnificence of normal birth to caregivers who rarely see it? Is it wrong to want to be a pioneer again? Is it wrong to want to reclaim a little faith in our bodies our culture views as defunct? Does that warrant this judgement of intended machoism? Is this how resentful people are of women who want to have natural births, that they will think them as megalomaniacs for going through the pain involved? If we were quiet about the pain would they feel differently? A martyr is someone who dies for her cause. I have never ever known a woman who would not throw herself on the floor and subject herself to unanesthetized surgery if there was evidence her baby was in immediate danger. This is not to say people don't sometimes make bad choices. It happens. But if we're talking about owning the sensations of labour, if a woman is paining, it doesn't mean she's dying, it means she is expressing a tremendous amount of raw, natural power. She is WORKING it. And if you can't stand the heat, you should get the hell out of the kitchen. When she's labouring she needs support and encouragement like the marathon runner who is at mile nineteen and all systems look to be shutting down. She doesn't need jugement about her intentions. Trust that if she can't take it or if there's danger, she'll do what she needs to do. That whole "feminist machismo" assumption is one of the most disempowering things I have ever heard, and it speaks of how little we regard the process that gets us here and those who have laboured to do so in heroic, miraculous grace. It speaks of a woman's intentions to experience birthing pain as misguided, and of not being smart enough and too stubborn to seek help when needed. Shame on us.

To be honest, there IS a tremendous ego boost to having birthed naturally. Huge. But it's a healthy one, not the macho kind. After that baby has come out naturally and you realize you did it all on your own steam you usually feel like a consummate badass. And is that so wrong? You haven't done it at anyone's expense, in fact, it has contributed to your and your baby's health. Shouldn't it be okay to feel great about that? In my doula logic I believe the confidence boost a woman receives from either having a great normal birth, or a difficult birth in which she may have needed interventions for but gave what she felt was her all, is one of the best springboards from which to leap into motherhood. Motherhood is joyful and amazing, but it's hard. And it's forever. To start out that relationship feeling like you can do anything, gives you RESOURCES. There is no Epidural Fairy who comes in the middle of the night to save your ass when your nipples hurt and the baby is waking up for the fifth time in a row. You are struggling, but you remember: you have given birth. You can do anything.

I ran into another neighbour of mine walking with her toddler and her new baby. Her first birth had been very long and she had had an epidural. She felt like she did great, but was a bit disappointed how it turned out. She wasn't sure she wanted to try it naturally again, but ended up doing so.

Lesley: "Jen, you had your baby! That's so great! How did it go?"

Jen (beaming): "I did it NATURALLY!"

Lesley: "Yay, that's fantastic, good for you! Do you feel like a rock star?"

Jen: "I AM a rock star. I feel like I could fly".

Enough said. "In glory and awe I have given birth, and found therein, my Self, my Child, and my God." -Kim Miller

Friday, April 22, 2011

Doula Work Hours : Finding Balance

Doulas are known to be extremely accommodating. We commit ourselves to staying at births no matter how long they are. That means slipping from our beds at 3am, without knowing as doctors, nurses, and many midwives do, when we will be home. If the birth is 3 hours, 30 hours, or 3 days, so be it. We are there. We quietly dip outside the birthing room with our cell phones when the sun rises and there is a lull in labour to reschedule our day packed with pre/post natals and re-arrange our childcare that becomes necessary after a couple of days away. Ah, there goes the day off planned for the week, and if the birth is really long, there goes the day off next week too in order to catch up on meetings. If the birth is super long and someone else went into labour early despite your attempts at good scheduling and you have to send a backup, well, there goes that income you had planned on too. It is crazy work, and it takes a very strong and giving spirit to do it happily without burnout. Thankfully, the rewards of birth attending are HUGE. I come home after a great birth or prenatal meeting high on good feelings of connection and the knowledge that I am doing something meaningful with my life.

The nature of a doula is usually one of givingness. To everyone. This can leave us sometimes feeling like we're failing everyone, our clients and our families, because we cannot clone ourselves and be fully present for all those people in our lives. It is extremely important, and you will see this as you grow into the work, that boundaries surrounding your pre/post natal meeting hours are essential.

I have kids in school. To see them off to school is important. To be there when they get home or soon after is important to me and to them. This is because usually at least once per week they miss me for a good chunk of time. Sometimes, like this week, there were three evenings in which I was there for neither after school nor bed time. This is hard on kids. It is crucial to find balance.

I schedule my meetings during school hours, from 10 to 3. This is not necessarily convenient for many clients who work, but as they usually take periods of time off once in a while to see their doctors or midwives, I usually suggest booking me in when they have that time off. I do not work (unless it's a birth or an event like a "Meet the Doula" night or apprentice gathering) evenings or weekends unless it is absolutely urgent. Sometimes I cave and meet with people at 9am or at 4pm. This is often NOT good for my family. I have to police myself firmly to not make that a habit. I arrived home at 3am one day this week, with a meeting scheduled at 9am. Constitutionally, I can stay up for 2 nights, down a coffee, and teach a 9 hour long doula training workshop without much issue. But it's not about me and keeping my schedule at this point. I realized if I made my 9am, which I should not have scheduled anyway, which I did out of guilt for not seeming accommodating enough to my beloved clients who work hard to schedule with me, that would be a LONG time away from my family. The after school, the dinner, the night time, AND the morning before school....for the second day in a row with many other births coming up, was getting a bit much. Those precious couple of hours to snuggle and catch up with our children, from toddlers to teens, are what nourish us all. We can go back to our work knowing everyone feels somewhat tended to if there is that reconnection to the home and hearth.

Another thing that makes not keeping schedules a total drag for my family is how hard my husband has to work to hold down the fort. He has his own stressful job. It's nine to five most of the time, but when you start feeling like a single dad of four, doing all the cooking, cleaning and child minding instead of his regular share so I can work, this can be a tremendous strain. He is the best doula husband ever. It is no easy feat being a doula's partner. His patience for my crazy birth attending hours has widened a lot over the years as he honours the importance of my job. But when it comes to sneaking in those little extra meeting hours in? No. Patience goes out the window, and I don't blame him. It's not only the days I'm not there, but if I arrive from a long birth at 8am, I usually need to sleep a bit, which means more time he is "on". He takes it in stride gracefully, and I am really grateful for that, but I totally understand why sneaking in those 4pm meetings, leaving supper to him AGAIN is a starting to ask a lot.

When we're starting out as doulas we're just so thrilled we get to go to births, and tend to bend over backwards to run any time and any place our clients want us to be so they are happy with us. As your practice grows, you will need to keep that in check and figure out what will work for your family and what will not. Yes, it is true, some clients may not hire you because they simply cannot make those day time meetings, but that's okay. I have a large enough practice that when one one client cannot take me, there are usually several more willing to take their place, and that will eventually happen for you to. There is a strength and grace and professionalism about someone who keeps strong boundaries. As doulas, we model mothering to our clients. To model the importance of family and boundaries is all part of the work.

And don't forget, there is not just work and family, there is you too. I always try to schedule a day off for my self during the week. I catch up on sleep, take long walks with the dog, go shopping, go for a long run along the lake shore, etc. It often doesn't work out because of births necessitating rescheduling of appointments, but when it does, I have to FIGHT the urge to sit down and work on administrative stuff or tend to all those little work-y things I "should" be doing. If I am going to model to my new mothers that self care is essential to harmonious parenting, and that they must "sleep when the baby sleeps" and not worry about messes and loose ends at work when there is a moment to chill out, I have to walk that walk too, otherwise my message is empty. I can only find true balance when my own self feels nourished enough to have plenty to give away.

As hard as it is finding balance as a doula, while I have my moments of stress and overwhelm, I do feel satisfied with most aspects of my life. I love my family and I love my work. And oh, I love my time to myself. If I don't get to be alone with my self or with my husband sometimes nothing runs as well. When guilt entered our culture for self-nourishment I'm not sure, but it is the ugly demon we need to keep fighting off in order live peaceful lives. Sitting in front of the tv in jammies on Sunday night is healing. Lying in bed reading a trashy novel when the house is a mess is a spiritual practice. Spontaneous kitchen messes with the kids are godly. Mother and work your heart out, sure, but have fun too.

Thursday, April 7, 2011

A Rose by Any Other Name...Birth Speak

I have been noticing in the doula world some stuggles over words. We have so much to do, so many balances to create, so many environments to improve. Some of these struggles are completely spot on and need addressing. Some verge on what seem to be an attempt to be more unique or less mainstream than the average bear. Words most definitely have the power to make us distinct. Language is very important, no doubt. If I'm standing up strongly for myself and creating a stink over injustice, I don't like to be called a bitch. Calling someone "sweetheart" in a way that's clearly condescening and sexist, instead of in a loving, nurturing way is awful.

There is tremendous power in words and we do need to be careful. But sometimes quibbles can be much ado about nothing. Yes, apparently I am waxing Shakespearean this evening. I don't love the quibble over the word "contraction". Yes, while the endorphin suffused state of birth in no way feels emotionally like a contraction but an expansion of consciousness, in reality the uterus most certainly contracts. Hard. Calling it a wave or an energy rush is not a bad thing, but really, it doesn't change the fact that a uterine contraction is occuring. Calling it another name might make it seem less "hard" (I consider it to be a word referring more to simple mechanics than to Medicine) and perhaps more spiritual, (and in our culture this desire for a shift of balance in birth perception is certainly helpful for many), but I am perfectly comfortable with "contraction". The uterine contraction causes a heck of a lot of sensation, and while I understand this phenomenon is perhaps not what some people want to focus on in their birth experience, really, that big sensation which goes hand in hand with the mechanical uterine contractions seems to take center stage in most labours regardless of what we plan or hope for.
I have noticed that many people don't like to use the "p" word with regards to know what I'm talking about.....pain. There have been several terms generated to shift perception surrounding the birthing sensations, but in my humble experience both personal and in birth attending, I tend to believe birth hurts, no matter how you try to pretty up the word. But the pain isn't a bad thing. That strong, strong sensation creates the flow of endorphins, and our experience of it raises oxytocin levels so the next contraction is even STRONGER. We birth hopped up on that beautiful " 'ormone of luve", which is guided and driven guessed it, pain. Whether they plan to or not, the vast majority of women feel some level of pain in labour. Instead of quibbling about the word, perhaps shifting the focus from the pain as being some nasty by-product of the childbearing process that we "shouldn't" have to suffer through to being a noble, healthy challenge we are absolutely capable of moving through would be more helpful. Call it an interesting sensation, call it a wave, sure...that doesn't hurt. But the sensation still does. And that's okay.
I see more and more doulas not seeming to like the word "training" for the process by which doulas learn their skills. The definition of training is: "organized activity aimed at imparting information and/or instructions to improve the recipient's performance or to help him or her attain a required level of knowledge or skill." I believe in training. Where I veer from most doula training organizations is that while I believe in good training including apprenticeship with an experienced doula, I don't care much about certification one way or another. In the doula world that piece of paper, while it is great because it means you did what was asked according to someone's made up standards, it in NO way means you're "done" learning. It in no way defines the greatness of a doula. Frankly, it means little to me. I have doulas on my team who are certified and who are not. What attracts me to them is their integrity, reliableness, passion, compassion, and a sense of knowledge I get from them just by speaking to them casually about birth. We develop through constant learning and continuing experience. So while the piece of paper stating "qualifications"is not so important to me, the fact they took the time to invest and immerse themselves into the preparation or "training" of how to be a doula is. There is a basic level of skill being a doula needs. I don't want to say "required" because that's too rigid. While the learning is life long, there are basics to know. You might want to know what a cervix is, for example. You need to know how to listen actively. You need to understand the process of labour and how women experience it. You need to know some tools to help. It's not all hearts and flowers and broadcasting love. So doula courses DO train doulas. Whether we want to claim that word "train"or not as what we do to prepare doulas is up to us, but I am happy with the word. I do not consider it too mainstream. I don't think it necessarily leads to an assumption of a means to an "end" of learning and major standard of pratice focus over skills. I don't believe it's about a check list of qualifications so you can call yourself a doula. It's about basic skills, information, and personal growth so that all participants can find their unique path and expression of the work. I'm sticking to the term "training" with impunity because I think it's a good word for the process of learning basic doula skills.
I'm not so down with the term "delivery" for the receiving of babies. What I don't like about it is that it implies the attendant "delivers" the baby. While they may be actively helping in some cases (whether it's needed in that situation or not), I've always kind of felt that mothers deliver their babies into the world. But I won't argue with or correct someone who uses this term.
You know what word I really don't like? "Doula"! It rubs me in all kinds of wrong ways. It comes from the Ancient Greek word "slave", for crying out loud! And a bonded slave at that. While the ancient lady of the house was birthing and mothering, her maidservant hung out with her and carried out a very noble role, but maybe not necessarily with the love and passion we modern doulas bring to our work because we do it from a place of free will and choice. To tend to women in their childbearing year is an honour. But the ancient maidservant was probably bought into the family and would have been stoned to death if she didn't carry out her role, like it or not. I can't think of one great other word describing what I do, but I must say it has never fell comfortably out of my mouth. Dooooouuuullllaaaaaa. It sounds kinda flakey to me..even a little romantic. Plus, half the people you mention it to say, "say what?" But hey, it is very deeply entrenched in our modern language, so instead of quibbling about it, I just go with it. It doesn't really change my life so much. Whether I'm called a doula or a birth attendant or an accompagnante, I love the role I play. A doula, the essence of the work being summed up by this popular word, is what I choose to call myself, whether I dig the acutal term or not. It's what people know and respond to. Really, "a rose by any other name would smell as sweet."