In which I briefly discuss a very non-brief birth

I'm just back from attending a birth; I am very tired but I want to get this out.

Leigh told me I will learn something from each birth I attend, and to write it down fast after the birth otherwise I'll forget. So here goes: I learned patience and trust.

This birth was long. Not totally-outside-the-realm-of-normal long, more like the kind of long that as a doula you hope your client doesn't have, because you'll be gone so long that your kids will forget your name and you'll forget your own phone number, not to mention go into credit card debt paying the babysitters. It was that kind of long.

This client wanted to stay home. She didn't want a home birth, but she is a very natural-minded person who had no interest in labor augmentation, pain medication, or intervention.

So we stayed home.

Honestly, part of me was dying to "do" something -- listen to the baby with a fetoscope, get mom's blood pressure, something. But I purposely didn't bring anything with me, because it wasn't my role. I was just there to support.

The dad very strongly believed that his wife could do it. She believed she could do it, but she had moments of doubt, as most laboring women do, and moments of realization that she'd been awake for 48 hours and contracting every 5 minutes of those 48 hours and was very very tired. But he was a real rock for her. Sometimes she would say, "Let's go to the hospital," and he would gently tell her that going to the hospital wouldn't change anything (a concept that is completely foreign to most women. Or, as Leigh says, "They don't have any magical baby machines in the hospital.") I agreed, but it was still hard for me, especially as I became increasingly tired.

But we stayed home -- not until the last possible second, not so long that there was a chance she'd have a car-birth -- but long enough so that I had watched her body go from closed to open, and her baby from high to low, without any assistance, and it was incredible. It was amazing.

In which I get back to the grind!

I am back to my midwifery studies after taking a break. We had a family situation that required my full attention; things seem to be back to normal now. I missed learning. I put away my midwifery books and instead read some really stupid novels that I did not enjoy although the reviewers on amazon.com seemed to love them. There's no accounting for taste, apparently.


Something did happen while I was on my break, which was that I attended an interventive birth -- and I didn't feel that upset about it. Normally I feel icky after attending a hospital birth like that. This time I was still so wrapped up in my own situation that I didn't feel much of anything. And that was a blessing. Taking a step back emotionally from my doula clients and their births was a positive experience. After all, they are hiring me because I'm a birth professional, and professionals are able to draw the line.


Today is MAC day. I'm not sure what the acronym stands for -- the M is midwives or midwifery -- but it's for all the South Carolina midwives and two of my friends will be taking their oral exam, the last part of licensure for South Carolina. I wanted to go but paying for all-day babysitting is prohibitively expensive and Dustin doesn't have any more time off work this year (although he will probably be furloughed again in December. Suck.) I'll try to get there next year. I do want to see the peer review process.

So I'm back to the grind. Which means that I'm writing this while Sydney sits in my lap and the dog chews something and I hope that we will all (except the boys) get naps today!

In which I learn to trust the process, and wear comfortable pants.

Ohhhhhh mahhhhhhhhhhhh gawwwwwwwwwwwwwwwd, I don't think I could have been wearing less comfortable jeans unless I'd been sweating and they were made of leather. Seriously. It was a pair of jeans that my mom bought me during a super-fast shopping trip while I was in Michigan a few weeks ago -- it was literally hours before the wedding started. I found a really cute pair of jean capris and she went find a second pair just like it, and she couldn't find the exact same ones, so she grabbed a "similar" pair, "similar" in this case meaning "looking somewhat like it except not meant to be worn in any situation where one might have to attempt sleeping in these pants." To give you some idea, dear readers, of the extend of my discomfort, let me say this: there is a belt buckle sewn into the BACK of these jeans. Ugh.

In my defense, I was under the impression that this birth would move quickly. Also, in addition to torturing myself from the waist down, I hadn't washed my hair that day. I think at one point the laboring mom actually looked at me and shuddered at my overall grossness.

After returning home, I immediately got on oldnavy.com and bought two pairs of cotton yoga pants, 2 cotton tshirts, and 2 long-sleeved shirts (I'm skinny now, so I get cold, yo). I'm going to make two birth bags and put one in my car and one in my house, and include the clothes, dental floss, travel toothbrush and toothpaste, travel deodorant, hair ties, and maybe some of those face cleaner wipes. Because I really never want to feel as gross during a birth as I have recently.

What I have learned recently: to trust the process.


There is such a huge difference for the mom and the experience when the provider trusts the process versus a provider who does not believe in what she's doing. I can see that a lot of it is experience -- it takes a lot of birth experiences to believe in birth. Sometimes things go wrong -- without any warning -- and often it doesn't go the way it "should," as prescribed by physicians in the 1950s. Here is Friedman's Curve of expected dilation.


The Friedman Curve -- which is adopted by hospitals and written in the blood of obstetricians -- is kind of a hot mess. Here's a quote from BirthSource about dilation

Current definitions of labor protraction and arrest may be too stringent, Dr. Jun Zhang of the National Institute of Child Health and Human Development, in Bethesda, Maryland said at the 2002 annual meeting of the Society for Maternal-Fetal Medicine. "And the long-accepted Friedman curve may not be an accurate description of normal labor progression, according to a new analysis of data from 1,329 nulliparous women aged 18-34 undergoing singleton, vertex presentation deliveries following spontaneous labor," said Dr. Zhang.

Based on the speed of overall labor progression and current cervical dilation, Dr. Zhang and his colleagues calculated the expected traverse time for the cervix to reach the next centimeter and the expected rate of cervical dilation at each phase of labor. "Our curve is very different," Dr. Zhang said, pointing out that on his curve the average was 5.5 hours for progression from 4 cm to 10 cm, compared with 2.5 hours on the Friedman curve.

"We also didn't see a deceleration phase," he said, noting that in 1978 Friedman modified his curve, but the distinctive sharp upturn remained, as did the deceleration phase. "Our data suggest that most women enter active labor at different times, mostly between 3 cm and 5 cm dilation, and even in the active phase the speed of progression varies from person to person," he further explained. The median time for cervical dilation to progress from 4 cm to 5 cm in the present study is 1.7 hours. And for fetal descent, it could take 3 hours to progress from station +1 to +2, and an additional half hour from station +2 to delivery, he added. "Therefore, the definition of protracted descent or arrested descent appears to be too stringent in current practice," according to Dr. Zhang.

Generally, when there is a plateau (stopping of progress) of two hours in Friedman's curve while in a non-medicated active labor, or of three hours in active labor with an epidural, then "failure to progress" is the diagnosis and C-section is indicated. Of course, evaluation of the "4 Ps" -- Power, Psyche, Passenger, and Passageway (basically this means the force of labor, mental preparedness of the mother, the size and position of the baby, and the size of the birth canal) must be made to see if there is a correctable measure.

A long plateau is when a typical hospital provider generally starts to freak out (about malpractice, perhaps?) and push for interventions like breaking water, giving pitocin, and suggesting that the mom have an epidural so she can rest since she's obviously exhausted -- whether or not the client says she's tired. I've had a lot of overnight labors. I've only ever attended one where the woman has said she's exhausted. (And it was a woman who had not followed my suggestion that if her labor began while she was sleeping and she wasn't have contractions yet, she should try to go back to sleep, or at least rest. That might have made a difference.)

In a different setting, with a different provider, nobody freaks out when the labor doesn't progress as it "should." In fact, there are no "shoulds." As long as everyone is healthy -- baby's heart rate is fine; mom is eating and drinking and peeing and resting when she can -- the labor simply continues. The provider might consider some alternatives that would gently move the labor along -- changing positions frequently, homeopathic remedies, eating and drinking, resting, discussing any psychological issues the mom may have surrounding the labor and birth and impending motherhood -- but she doesn't force.

Trusting the process is somewhat different from sitting on my hands, which I wrote about last month. Sitting on my hands was at a birth where everything was progressing as it "should," but I felt like something needed to be done. See, I'm inexperienced! Trusting the process is about stepping back and looking at the facts and making decisions based on this individual situation, while taking into account the midwife's experiences.

A quick note about midwives who work in hospitals, also known as Certified Nurse Midwives. I believe that many of them trust the process, but the physician who is supervising them does not, and they are at his or her mercy. At a hospital birth recently, a machine kept malfunctioning and recording incorrect information; the baby was fine but it said that the baby was in distress. The CNM would come in and say that they had to get it fixed because if the attending physician saw the records, he would "go through the roof." Did she trust the process? Well, yeah, she knew the baby was fine. But she was under the direction of the physician who clearly did NOT trust it -- or maybe because he was supervising multiple labors simultaneously (without ever seeing anyone face-to-face) so he was unwilling to look at the individual labor.

In which I extol the virtues of the Cochrane Database and evidence-based practice

Of all the websites I use for wasting time, The Cochrane Collaboration is probably the one I should make my homepage. Rather than learning how to make a hula hoop out of pvc-piping and a vice grip, the Cochrane Database has systematic non-biased reviews of health care studies.

About The Cochrane Reviews:

"Based on the best available information about healthcare interventions, Cochrane reviews explore the evidence for and against the effectiveness and appropriateness of treatments (medications, surgery, education, etc) in specific circumstances. Designed to facilitate the choices that doctors, patients, policy makers and others face in health care, the complete reviews are published in The Cochrane Library four times a year. Each issue contains all existing reviews, plus an increasing range of new and updated reviews."

Some things I learned tonight from about 15 minutes spent on the Pregnancy and Childbirth Topics page:

• They spell cesarean, "Caesarean" -- so if that's what you're looking for, there's how to spell it. Otherwise you might not get any hits.
  
• In Amniotomy for Shortening Spontaneous Labour, the results were "The evidence showed no shortening of the length of first stage of labour and a possible increase in caesarean section. Routine amniotomy is not recommended for normally progressing labours or in labours which have become prolonged."
• In Antibiotics for mastitis in breastfeeding women, "The review included two studies and approximately 125 women. One study compared two different antibiotics, and there were no differences between the two antibiotics for symptom relief. A second study comparing no treatment, breast emptying, and antibiotic therapy, with breast emptying suggested more rapid symptom relief with antibiotics. There is very little evidence on the effectiveness of antibiotic therapy, and more research is needed."
• In Vaginal chlorhexidine during labour to prevent early-onset neonatal group B streptococcal infection, "The review of five trials (including approximately 2190 term and preterm infants) showed that although chlorhexidine reduced the number of bacteria that passed to the babies, the studies were not large enough to say whether it reduced GBS infections or not."
  

I found the GBS study the most interesting, because you would assume that if the number of bacteria passed to the baby is reduced, the GBS infections would be reduced also, and it's not (as far as the review shows. Probably more research is needed. Isn't it always?)

I love being a doula, and helping women give birth, but sometimes being at a hospital can be so disheartening. Hospital protocol often has nothing to do with research. Withholding food and drink in labor to prevent aspiration "just in case" moms need an emergency c-section under general anesthesia is ridiculous -- in a study that included 78,000 laboring women who ate and drank, there was not one case of aspiration (source: The Thinking Woman's Guide to a Better Birth). Continuous fetal monitoring for low-risk pregnant women doesn't improve outcomes any more than intermittent monitoring, and may in fact raise rates of c-sections due to the high false-positive rate (same source). And yet, I see the former at every birth, and the latter pretty frequently. Women who are essentially told to run a marathon are told in the same breath to go the distance without food or water. An IV is not meal replacement -- in fact, they often overload the mom with too much fluid, causing her kidneys to work overtime -- and they are invasive and painful.

Glad the next two births I'm scheduled to attend are not at hospitals.

In which I attend a whole bunch of births

with evidence!


(Yes, I hold every baby in my left arm, and only wear solid-color shirts.)

Here's what I've learned lately: I can't predict anything. I can't assume anything. Even when the evidence is there after hours of labor and I'm thinking that I know -- I know! -- in which direction the labor is heading, I usually don't.

I have learned to turn off that aspect of my brain during labor and just focus on the task at hand, like holding an emesis basin while a mom throws up into it. Otherwise I start thinking, "Wow this really isn't going well, I hope she doesn't end up with a C---" (and baby is born vaginally 20 minutes later.) "Wow, this is going fantastic, this baby is going to be here in an hour--" (and 17 hours later, the baby is born.)

It seems antithetical to the idea of holistic midwifery to put my ideas and my experiences on someone else. Every birth is different. I learn something new at each birth. And what I've learned over the last few years is that I just can't predict anything. Women surprise me. Labors surprise me.

I've progressed a little in my school, I'm now in "Orientation" and have requested my curriculum. My mentor just graduated and took the NARM exam. Recently I talked to another student who told me that I'm making my assignments more difficult than I need to; I'm over-thinking them. Really? Me? The woman who can't order food without having an internal dialogue (complete with debate of the pros and cons) between a grass-fed hamburger that is cooked medium versus medium-well?

I guess it's really not that surprising.

Another example of how I have to be like Nike:


and Just Do It.

Birth attendants: worth more than burger-flippers at McD's, I hope.

I feel frustrated when birth work isn't valued, particularly by the women who claim they want it. Most of the time, women who want doulas realize the value of having a doula. But there are some who just don't get it. I think this is more with regards to doula work than midwifery. With midwifery, the care is more tangible. With doula work, it's a little more difficult to see on the surface; we're not always "doing" something.

(I could easily go off on a tangent right now how our entire society and our whole nation doesn't seem to value birth work, versus other countries who subsidize doulas. See "Sicko" and note the part in France with the postpartum doula, who the government provides for free for all women. And I don't want to debate France, since so many people in our country are anti-France; I'm just making the point that the French value birth work. And we don't. Le sigh.)

I'm also thinking about trusting my instincts with regards to the doula clients I take. I've gotten burned over that one. It's just so difficult for me to turn down doula clients. Here's why:

1. I do this because I want to help women have positive birth experiences, and most of the women who hire me choose to birth in a hospital, and they need all the help they can get!

2. There are eleventy-million doulas here, far more doulas than women who want a doula. So getting hired makes me feel good -- I feel validated. I realize that this is my ego talking, and I shouldn't look at it like it's about me, because it's not. When I was pregnant with Allegra, I met several doulas and none of them were the right one. It wasn't anything personal. And when someone I meet with chooses another doula, I feel okay about it because all of the local doulas I know are fantastic, and I usually feel confident that the woman will be in good hands. But it does feel good to get hired.

3. Money. Being a doula is a business, and I deserve compensation for my work.

I spend a lot of time and energy on my clients. Even if I'm not in constant communication with them, I'm thinking about them, I'm googling things and learning things that might help them with their birth, I'm emailing with them or talking on the phone. When I'm on call, my life is on hold. I'm usually sleeping with one ear open, as it were. Going through Helping Hands, my apprentice workbook, most midwives said the most difficult part of being a midwife is that your client owns you, and I'd agree. It can be sucky. Emily once had a client go into labor when we were at a party that was really far away. I've had a birth on Christmas eve and Christmas day. Tomorrow I'm going for an interview with a woman who lives an hour away.

I've attended a birth that started Sunday evening and she didn't give birth til Wednesday evening. Leigh once said that midwives need their faculties about them after the baby is born; but that isn't true for doulas! We work like mules. We can totally deplete ourselves, physically and emotionally, and we often do.