Tuesday, May 10, 2011

Me, The Doula?

A friend of mine, RM, gave birth back in March to a beautiful baby boy, her second. She asked me to attend the birth as her birth coach/doula, despite my rather significant lack of actual experience or training in such a role. I'm not sure having given birth twice really qualifies me as a "doula," per se. But I was honored and touched that she trusted me to be there and help her through it, and now, having done it, I am so glad I agreed!

I admit to having been quite hesitant at first. Would I know what to do? Would I be comfortable seeing, er, "those parts" of my friend? Would she be comfortable with me there? Would I be unfortunately affected by any blood or fluids? And, what was I supposed to do?

We had watched "The Business of Being Born" together, in addition to other reading we had done, and we were both very well aware of how easily the natural birth process can be derailed by accepting or being offered interventions at all, or too soon, or unnecessarily. We were both very conscious of what was called in the documentary "the cascade of interventions." This is the vicious cycle of intervention-leading-to-intervention that usually begins innocuously enough with, "Would you like pain relief?" or "Would you like the epidural now?" For many women, they get the epidural, they're happy, the baby comes out at some point later, and everything is fine. But for a significant percentage of women, it's not quite so smooth a road. For many, the epidural can cause a sharp drop in blood pressure in the mother, which can lead to fetal distress. Alternatively, the epidural can slow labor, which can cause the labor process to be labeled "failure to progress," which can prompt the doctor to order Pitocin to "move things along." I've discussed the dangers of Pitocin briefly before, but, as a reminder, the use of Pitocin can sometimes lead to otherwise unncessary c-sections due to fetal distress, usually signified by a sudden sharp drop in the fetal heart rate, not to mention other stress on the mother and baby because of the strong contractions produced by the Pitocin.

Back to the birth I was actually attending, though. Once there, over the next few hours, I relaxed and fell into my role. RM's husband and mother-in-law were there with her at first, and I felt like kind of a third wheel. Fourth? Anyway. The nurse came in to let RM know that she could have pain relief whenever she liked. She was dilated somewhere between 3 and 4cm. She wasn't sure it was quite time for the epidural yet, and she also wasn't sure about other pain relief options, such as Stadol. She didn't want to risk slowing or stalling labor, and she also didn't want to risk a sleepy or lethargic baby if he came too soon after administration of drugs. She also wasn't convinced that the narcotics would help her at all. She was definitely uncomfortable, though.

The nurse mentioned that the anesthesiologist was about to go attend a c-section, and he wouldn't be available for about an hour if she declined the epidural just then. She finally decided, after some discussion with me and her mother-in-law (who is a nurse), to accept a dose of Stadol, which should make her more comfortable for the hour during which the anesthesiologist would be unavailable, after which time she could think about the epidural again.

The Stadol worked perfectly, and she was quite content (and a little high) for about an hour. Her contractions continued at a steady pace, and her mother-in-law and I chatted while her husband dozed. Finally, my friend started to come out of the drug-haze, and the nurse came back to check on her. She had been comfortable, and the contractions were manageable, so she decided to continue to hold off on the epidural, but she also declined another dose of narcotics.

Over the next several hours, labor seemed to come almost to a halt. The contractions weren't getting stronger or closer together. She wasn't really dilating at all. It was somewhere around 11:00 P.M. Her husband was sleeping. Her mother-in-law had gone back to RM's house to be with her older son (and relieve the nanny), and it was just the two of us to talk over her decisions. I'm pretty sure that's how she wanted it.

The nurse came in to offer to remove the fetal monitors for a while so that we could take a walk to help move things along. She said she could keep the monitors off for 40 minutes, then have them on for 20, then off again, if she wanted. This is called "intermittent monitoring," and in my research and reading, I had learned that typically you have to demand intermittent monitoring, since they prefer to keep you on the monitors at all times so they can keep an "eye" on the baby. I was very impressed that the nurse actually offered intermittent monitoring! I strongly felt RM should get up and walk around, for her own sake as well as for the sake of helping labor along. We walked the halls and talked, mostly about birth and breastfeeding, for about 40 minutes. During that time, she had to stop several times for contractions, but when we got back to her room, she said she felt really good. She was put back on the monitors, where we saw that her contractions were still fairly far apart and not very powerful. This was unsettling. After almost four hours of labor, it seemed like something should be happening, especially since this wasn't her first baby.

She rested for a bit, then decided to try walking again. This time, she didn't experience a strong contraction for the entire 40 minutes, and when we returned to her room, she was tired and worried. So was I. I guess I can selfishly mention about here that I was already noticeably pregnant, and it was late, and I was also quite tired, although I can't say I was as tired as she, since I, thankfully, was not in labor!

The nurse came in to check on her and said that the doctor planned to come in around 6:00 in the morning to break her water if that hadn't happened by that time. It sounded far off, 6:00 did, and it seemed like surely she should already have had the baby by then, if things continued as expected. Except. Except labor wasn't...labor. In fact, she was barely feeling anything, except tired.

The nurse at some point said that RM did have options. She could just go home if she wanted, and wait, and see if labor eventually picked up on its own. She wasn't obligated to stay there. She didn't have to accept any interventions. I was actually kind of amazed by this, too, since most hospitals just want you in and out, baby in arms, within a reasonable amount of time. And it wasn't like she wouldn't eventually have this baby! RM felt very strongly, however, that she couldn't go home still pregnant, and that she couldn't be pregnant another day. She was already past her due date, and she was very uncomfortable, and she intended to have this baby that day. I completely understood!

I went to lie down for a few minutes while she rested, then wandered back over because I was bored and couldn't sleep. We talked and watched the discouraging monitors. She didn't feel like walking anymore. Suddenly, I noticed that the baby's heart rate, which had been between the 120s and 140s, suddenly dipped into the 60s. At first, I thought it just meant the monitor had shifted and lost the heartbeat, but then three nurses charged in, and I realized it was a real emergency. It appeared the baby was putting pressure on his umbilical cord and causing himself distress. I got out of the way while they gave RM oxygen through a mask and had her shift positions, finally ending up on her hands and knees on the bed, to try to take the pressure off the cord. His heart rate stabilized pretty quickly, the crisis was averted, and they helped her back into a more comfortable position. They asked her to keep the oxygen going for a while to make sure the baby was getting enough.

The nurse went to report to the doctor, then came back to say that the doctor was aware of the "spontaneous deceleration." She said that if it happened again and they couldn't get him stabilized, it might mean she would need an emergency c-section. The nurse suggested that it might be a good idea to have the epidural, just in case, because that way they wouldn't have to knock her out completely if a c-section became necessary. The anesthesiologist was just outside, not busy with anyone else, and he could come in right away. It would also give RM the opportunity to sleep, or at least rest, more comfortably.

RM was rightly worried about the use of an epidural when labor was already moving so slowly, but she was impressed with the nurse's making a strong suggestion, when before she had only said what was available. This time, RM decided to take the epidural, just in case. It was also only a few hours until 6:00, and she felt that if the doctor were going to have to break her water and possibly administer Pitocin to get the contractions moving again, she may as well already have the epidural. I was leery, mostly because I was concerned that if there was another emergency, she wouldn't be as mobile, so how could she get up on her hands and knees or whatever if that became necessary? But she opted for it, and I didn't think it was really a terrible idea, and I had a pretty good sense of how much I didn't know by this point, so I got out of the way while the anesthesiologist did his excellent work, and RM was able to relax.

As the nurse had feared, there was a second spontaneous deceleration, but the epidural wasn't so strong that she couldn't feel her legs, and they were again able to get RM up on her hands and knees, the baby recovered, and no further interventions were necessary.

6:00 came and went, and the nurse came back to say that the doctor was on the L&D floor, but another of his patients was ready to deliver, so he was going to attend that birth first, then come back to break RM's water and see if anything else was needed. He came back a little after 7:00. Her water broke, and the fluid was clear (i.e., no meconium, meaning the baby had not had a bowel movement in utero, which can be dangerous), but contractions did not pick up. He strongly suggested that she have a small dose of Pitocin. His words were, "I'm trying to save you a cesarean here." Now, with most doctors, that would not have impressed me. Indeed, it would have almost seemed counterintuitive to me. However, RM had researched this doctor, and he had been in practice for 40 years and had the lowest c-section rate in the county. In other words, he knows what he's doing. I felt strongly she should do it. Because she had given birth vaginally before, her body was prepared for a second vaginal delivery. Plus, labor was not moving along really, and once her water was broken, it was important that the baby be delivered relatively soon. It was worth trying the Pitocin, because if it worked, she'd have her baby soon, and she would avoid the c-section, which is the one thing she knew she absolutely did not want. She finally agreed to a small dose of Pitocin, just to help the contractions along.

Help them along it did! Just 10 minutes or so after the Pitocin was administered, she had dilated another centimeter, after hours and hours at 4cm. Not long after that, she started yelling, which she hadn't done before. She said the epidural wasn't strong enough, and OH MY GOD she wanted to push, and she was going to poop that baby out now! I realized she was in transition already, and it was a very different experience to be on the receiving end of that yelling, instead of the one doing the yelling! It's an amazing change to watch, from "whoa, contraction," to "HOLY CRAP!!!" I called the nurse in to give her a bolus of the epidural anesthetic, to try to help with the pain, at which point the nurse realized as well that RM was in transition. She begged her to wait until the doctor arrived before she started pushing. He was delivering another baby just then and would be there any time.

This is when everything got very exciting. The doctor arrived, RM's husband got into the mix, and I got to just step back and watch and offer an encouraging word when one came to mind. I also brought a damp paper towel for her husband to put on her forehead. Although I've forgotten a lot of the details of those last few hours of my first labor, I specifically remember my mom bringing me a cool towel for my forehead, and how good that felt. They broke down the bed to become a delivery table, and the doctor took up his post. He felt for the baby and said he was still pretty far up there, and it still might be a while, and he seemed to be a larger baby. In other words, she might be pushing for a while.

I could see RM's response on her face. "Oh no it won't be a while!" she thought, very emphatically, and when she was told to go ahead and push when she wanted to, she pushed. She PUSHED. She PUSHED. And, I'm not exaggerating at all, 10 minutes later, there was a head! TEN MINUTES. Now that's what I call pushing. A perfect body followed the head, and I couldn't believe how exciting it was to witness that. Everyone calls it a miracle, and there is absolutely no better word for it. You go from screaming straining woman to squalling baby just like that. There's just suddenly a baby there. It's the most incredible and exciting thing I've witnessed. I can't even describe it. I had an oxytocin rush! I was bursting with adrenaline! And I wasn't even doing anything, just standing there!

The baby was 7lbs., 2oz., a little smaller than her first (and not at all a "bigger" baby!). He was perfect and came out raring to go. RM became fixated on two things: Deliver the placenta, and give me the hell my baby so I can nurse him. Once she successfully delivered the placenta and that was done with, she watched impatiently from the bed as they did all the initial measurements and such over on the warming table. I stood by watching. I felt like I was on guard, standing beside him in his mother's place, making sure he was safe. The nurse offered RM food, water, whatever she wanted. "I just want to hold him," was her only response. "I just want my baby. I want to hold him." I was antsy, too, ready for her to have him back so she could get in that oh-so-important initial breastfeeding. I had also been drafted as her unofficial and unlicenced "lactation consultant," although I can hardly claim that title. I have no training, except for lots of reading and having nursed one baby.

After about 20 minutes, he was brought to her, clean and swaddled. The labor nurse promptly unswaddled him and together we helped her place him against her chest, skin-to-skin, so she could nurse him. I had forgotten how hard it is to hold a newborn to your breast. You need three or four hands. But she got him there, and he went to town. It was so beautiful.

I left about an hour later, still totally high on adrenaline, oxytocin, and a sleepless night, after getting a chance to hold him and getting a sneak peak at his name (which wouldn't be used publicly until his bris (ritual circumcision) the following weekend).

It was really enlightening for me to be at a birth but not giving birth. I was able to see some of the goings-on and listen more carefully to the "hospital speak," and I had the time and wherewithal to really consider every decision. Though none of the decisions would have affected me directly, RM is a very good friend, and I wanted her to have that satisfying and fulfilling birth experience that she deserved, that every woman deserves. Her first birth, though accomplished vaginally, had been quite traumatic for her, and I know she was nervous about her second being just as bad. I was so happy to see her so content once she had her son to her breast, and I knew things had worked out much better for her this time.

I was full of emotion for weeks after the experience. Just thinking about it could make me cry. I wrote her a note to thank her for the privilege of witnessing something so special, and she wrote back a very lovely note thanking me for being there. I knew I had helped somehow, even just by being moral support, butI also had felt quite helpless at times, because there was so much I didn't know, and there are so many things I wouldn't have known to do. I still don't. That's why a "real" doula has training, and attends lots of births. Because there's a lot to know, even if you're not the one actually supervising or devliering or doing anything medical.

Still, it's an experience I would repeat in a heartbeat, assuming I was physically in a position to do so. Right now, I think my own delivery has to be next on my agenda, and then it would be difficult to attend a birth when I had a newborn of my own. But one day, if another friend is having a baby and wants some support as she labors, and I'm available, I would be thrilled to participate again.

There's a specific Psalm that it is traditional to have beside a laboring woman's bed, to recite during labor, and to place in the newborn's bed. I'd like to transcribe a translation here, sort of as a concluding thought.

Psalm 121:
I lift my eyes to the mountains -- from where will my help come?
My help will come from the Lord, Maker of heaven and earth.
He will not let your foot falter; your guardian does not slumber.
Indeed, the Guardian of Israel neither slumbers nor sleeps.
The Lord is your guardian; the Lord is your protective shade at your right hand.
The sun will not harm you by day, nor the moon by night.
The Lord will guard you from all evil; He will guard your soul.
The Lord will guard your going and your coming from now and for all time.

(From the translation at http://www.chabad.org/library/article_cdo/aid/732833/jewish/Psalm-121.htm)