Tuesday, May 12, 2015

Turning Inwards

I had a lovely conversation with a doula friend the other week and I came away so happy and inspired.  Rarely have I met someone so centered and aware of their own body and their capabilities.  It is always delightful to meet with another doula and talk about birth.  We both agreed that we like nothing better than talking about birth.  So, of course we shared our birth stories.  Hers were so wonderful.  Throughout her first birth she would periodically check in with her body to decide what she needed to do next.  If I look back and review where my mind was at while in labor with my first, I will have to admit that I was completely focused on the pain and not at all aware of my body or what it was telling me.
It is surprising how easy it is to miss that essential point.  Most childbirth education classes spend the majority of their time discussing the stages of labor, playacting through pretend contractions, teaching optimal positioning etc...  Yet, it all seems so external.  We learn about these events but we spend little time really turning inward and figuring out what we'll need to do to cope mentally/emotionally.  You can know all the best positions in the world but if you're mind is stuck on the pain or on what's coming next, no position will bring relief.  You need to find your own inner focus.
The trouble with teaching a concept like "finding your inner focus" is that it will differ radically woman to woman.  There may be some similarities...every woman needs to turn inward to find that focus but how they end up doing that and what it actually looks like will be unique.  What is liberating about this concept is that you don't have to birth like anyone else!  You can birth exactly as your body is designed to birth and you can find freedom and happiness in that.
One woman shared her birth story with me and I'll share it now to demonstrate just how different we each can birth.  Her labors were pretty typical up until around 6 cm.  She would get to 6 cm and then progress lightning fast to 10 and pushing.  She had 6 babies and no matter how often she told her doctors and nurses, they still never believed her when she said it was going to be fast!  In fact, her last baby was born on the hospital bed without a doctor present because no one believed her that she was ready to push the baby out!!
So instead of relying on someone else's idea of how birth "typically" goes, I encourage you to turn inward and focus instead on what your body is telling you, and to trust what you know.  No one has a crystal ball into your uterus but you are the closest thing to a crystal ball.  You can turn inwards and find a deeper knowing about your body and your baby.  You can know things no machine can tell you.  Every machine used in birth i.e. ultrasound, electronic fetal monitors, etc... have a high false positive rate.  You can hardly do worse, and most often you can do better than a machine by remaining calm and confident.
If you're not used to this kind of inner meditation, please don't disregard it as not something you'd do.  Pregnancy and birth is the perfect time to stretch yourself and explore the unknown.  Just the fact that you will be birthing readies you for the unknown.  Embrace it.  Have confidence in yourself and in your body's way of birthing and let it happen.

Tuesday, April 28, 2015

The Most Important Thing First-Time Mamas Need to Know

I've been thinking a lot lately about the unique needs of first time parents.  I know I was once a first-timer myself, but still it's hard to think about what specifically would have benefited me--what I would have liked to have known before giving birth for the first time.  Plus, each person differs in their approach/experience going into birth for the first time.  Some women have very specific expectations and know a lot about the birth process and what they want out of it.  Others feel less sure, less experienced and feel good leaving themselves open to whatever comes.  I'd like to point out also that no matter how much a woman "knows" about birth beforehand; it doesn't mean she is prepared to birth.
I knew a lot before giving birth to my firstborn.  I had read millions of books (seriously) and I had attended a Bradley Childbirth class, which met for 12 consecutive Sundays for 2 hours each.  Talk about intense preparation.  I'd like to think that even though I wouldn't classify my first birth as a good birth, I still knew enough to make informed choices and surround myself with loving supportive people--which makes a huge difference.
So, having a lot of information meant that I could make informed decisions about my labor and birth.  It didn't mean that I stuck with my convictions--the opposite was true.  I didn't want my water broken or to have an episiotomy--I ended up with both, and when they were offered I gladly accepted them.  On the other hand, somewhere in my subconscious I avoided a cesarean by making sure that whenever I mentioned wanting one I was only in the presence of my husband and not one of the midwives.  I think that was my way of giving voice to the pain I was feeling without opening myself up to the possibility that I would be taken seriously.
I also had my mother and sisters there with me and my husband.  Unfortunately, at the time neither my mother nor sisters had experience with vaginal birth.  I say unfortunately because that meant none of them could give me the encouragement/support that I so desperately needed.  Having a loving, compassionate person with you at a birth is a step in the right direction, but if labor is long or complicated nothing beats having a trained professional by your side.
I've written before that sometimes a midwife can offer that trained, compassionate support, but the point I need to stress is that just because someone is a midwife does not mean that she will be with you for the duration of your labor or that she will necessarily provide the compassion and support that you need to birth your baby.  The same is even more true for obstetricians in hospitals.  Some are quite good at what they do and work hard to be present for birthing women, but the reality in hospitals is that your o.b. will only be available to you for brief periods during labor and then pushing.  Nurses are slightly more available, but not by much due to case load and staffing.  And it's sort of like playing russian roulette...you may get a nurse/o.b./midwife who you like and who is responsive to your needs but you might also get a caregiver who is tired/jaded/on a power trip etc...and end up feeling ignored/pressured during your birth.  Personally, it's not a gamble I'd want to make.
But, going back to first-timers, I did not think as critically about my caregivers before giving birth for the first time.  I wonder why?  It could have been over-confidence.  It could have been simple ignorance.  So, I guess in answer to the question what would I, as a first-time mama, want to have known in addition to basic knowledge of labor, would be that I should place most of my time and energy on deciding who is attending my birth.  Factors to consider when making that decision would include: finding out their experience, what are their views on birth, if possible reading reviews of other patients' experiences with them and knowing just how available they will be for you during labor.  If someone has a huge case load and will be bouncing between you and other laboring mamas, I urge you to strongly consider finding someone you trust who will be able to stay with you for the whole time.  You may be that first-timer who experiences labor as not as hard as you thought and feel confident in yourself and your partners' ability to do this on your own, but more than likely you will want someone who knows birth and who makes you feel good to stay with you, and you will not want them to leave...ever.
Imagine you are planning a trip into unknown and potentially dangerous territory.  You could read all you could about that place, but nothing would compare to the feelings of relief and confidence boost that you would get if you knew that an experienced guide would be with you the whole time.  You'd probably relax more, feel better about the whole thing and be able to really take in the whole experience without having to concentrate as hard on what's going on at each moment.  You could just give yourself over to the experience knowing there is a safety net to fall back on, just in case.

Tuesday, April 21, 2015

The Difference Between Midwives & Doulas

So, I can't tell you how many times I've told potential clients that I am a doula and heard, "that's like a midwife, right?"  I usually just pause, shake my head, and say, "nope.  really not anything like that."  I am now going to list all the ways that a doula differs from a midwife.  Keep in mind that there is a lot about our attitudes to birth that may be similar but what I'm talking about is what we actually do-the services that we provide.

A doula is concerned with the emotional/comfort/coping needs of the laboring mother and her partner.  A doula has nothing to do with the health and well being of mother or baby.  What this means practically is that while your midwife is checking heart tones and charting, your doula is checking your body for signs of tension, eyeing your partner to see how he's holding up, and working hard to stay calm and focused on your needs and the needs of your partner.

This isn't to say that a midwife isn't also concerned with your emotional state.  She very often is, but she also must concern herself with how you and baby are doing physically.  Let's just say there is a drop in fetal heart tones.  The midwife is busy trying to figure out why and to work out the best course of action.  In this scenario, it will be your doula who is by your side encouraging your partner to stay close and either applying gentle massage or just offering calm support and presence as you go through those tense moments.

A midwife is very like a teacher.  She has a lot of information/knowledge and very often has a lot of tricks of the trade that she can pull out to help when labor gets stuck or a specific complication arises.  A doula has her own tricks of the trade and these all involve fostering a deep and lasting bond between a laboring women and her partner.  The doula is most concerned with helping the mother own her birth and come away feeling heard, respected and loved.

The best analogy I've heard for a midwife is that of lifeguard.  The midwife believes in the power of birth and our bodies' natural ability.  She is on hand to spot potential complications and to deal with them.  A doula, on the other hand, is most like a mother.  She offers her care and love and also encourages her clients to stand on their own two feet.  She knows that the best mother is the one who imbues her children with inner strength and conviction.  She builds a warm cocoon of love and support and then encourages her children to fly.

Tuesday, April 14, 2015

The Art (Work) of Visualization

Using different forms of visualization techniques are becoming more popular for women preparing to birth.  Many women these days will have taken or are at least aware of Hypnobirthing classes where you learn self-hypnosis techniques and train yourself by repeating affirmations and going inward, or prenatal yoga classes with daily meditations/affirmations incorporated as part of your practice.

Visualizing a positive birth experience is a wonderful thing to do when preparing for birth.  It gives you a good focus and helps you calm any fears or concerns you may have about the process.  And as you all know, what you say and think has a strong correlation to your body and each influences the other.  For example, if you think, "Oh boy, my co-workers are all sick, I'm sure to get sick too."  The more you think that you are going to get sick the more likely it is that your body will respond and get sick!  However, if you say to yourself, "I am strong, my body is strong, this time I will not get sick."  You actually increase the likelihood that your immune system will fight any germs/disease and keep you healthy.  Now each does influence the other, so even if you're thinking positive, "I will not get sick," if you eat really unhealthy or neglect to exercise, your body may not be strong enough to work with your mind and keep you healthy.  The two, mind and body, are an inseparable pair.

Because your mind and body are so connected, it is important to note that when practicing a visualization technique you should be aware of the danger of practicing what I'll call, "wishful thinking" rather than an actual visualization.  The distinction is fine, but important.  True visualization involves going inward and examining your inner questions, concerns and then figuring out what you need to do and say to best prepare for and address that question.  For example, a mother who is worried about birthing a big baby may visualize her body getting big enough to allow her baby to come out.  She may say, "No matter how big my baby is, my body can grow bigger."  If she repeats this enough, she will start to believe it and then during the birth if fear or doubt creeps in, she can call on that visualization and affirmation to help her get through.
Now what happens if this mother is one of the rare few whose pelvis is actually too small to fit a baby through?  Will all her visualization preparation have been for nothing?  Is she destined to be devastated and regretful over her birth experience?  Not if she had been practicing true visualization.

The key is in the final step of the visualization process--letting go of outcomes.  You first do all the hard work of finding your question/concern, looking at it from all angles and figuring out what is in your power to do, doing that, repeating your affirmation daily, and then allowing your actual experience to unfold as it will.  If you have done everything in your power to prevent a fear from coming true or if you have spent time building up your confidence in your body and then you allow that there are other forces beyond your control that will play their part; you will be free to accept and experience your birth as it is happening without too much resistance or attempts to control the process.  When all is said and done you will know in your heart that you did all you could and this was just how your body and your experience unfolded.

Wishful thinking involves repeating an affirmation or practicing visualizing something that you want without ever doing the deeper work of examining your desires from all angles and taking steps to make sure it can happen.  Wishful thinking is wanting something with your mind without ever involving your body in the process.  As I said before, the two are inseparable.  You could say every day  all day, "I am going to win the lottery," but if you never actually go out and buy a ticket...no amount of focusing your mental energy will make it come true.

Take the time to figure out what is most important for you to know/have/experience in order to birth and then involve your mind and body in the process of achieving it.  Figure out the what, do whatever is in your power to do and then let go of the details on how you get it.  Trust that you will get what you need and that you will be strong enough to adapt and change and respond to your unique situation as it unfolds.

Tuesday, March 17, 2015

Artificial Rupture of Membranes...The Least Invasive Procedure With the Least Appreciable Benefit?

Artificially rupturing your membranes (AROM) seems like such a small inconsequential intervention when you compare it to interventions like pitocin augmentation or episiotomy or forceps.  And it's true, compared to those and others, breaking your bag of waters is not quite as rife with risk, but that is not to say that it is entirely without risk either.  If your goal is a natural intervention free birth and you've already established some clear idea of your stance regarding other interventions let me encourage you to think a bit more deeply about this one.  Here is some background from what I've read and experienced:

The most often cited reason for doing an AROM is progress.  When labor is slow or arrested many times breaking your waters is suggested as a safe way to speed things up.  One time I had a client who was laboring very well and making adequate progress and then the doctor came in 5 minutes before her shift was up and suggested breaking her waters since according to her, it had cut her own labor time nearly in half.  I couldn't believe such blatant misinformation!  In this case there was no medical indication, simply a desire to speed an already well progressing labor.  My client agreed (as who wouldn't when promised a speedy delivery?!)  The unfortunate result was that the contractions intensified, causing pain my client could not keep up with prompting her to request a narcotic for the pain, which then led to her being confined to the bed, which slowed her progress down considerably and as far as I could see only increased her frustration and discomfort.  A veritable snowball of interventions that began with in my opinion an unnecessary AROM.

Another example of AROM used to speed up labor is from my own first birth.  My first birth was long but not atypically so.  I was going on a good 18 hours of labor with steady progress but not yet complete dilation.  My mood was tense and tired.  When my midwife suggested that breaking my waters might speed up my labor, I latched onto that fact with all the hope and expectation of a dying woman being offered a cure.  My husband tried to remind me of what we had learned in our Bradley childbirth classes, but I was not convinced.  Anything that might mean an end to my pain was very very welcome.  In my case I was close enough to complete dilation that it did not cause any very severe increase in pain nor necessitate my requiring any other intervention. What did happen was that I ended up feeling as if I had failed somehow in my attempt to birth.  I felt like I needed the help of my midwives in order to give birth and that my body just wasn't able to get the job done.

With my third I again accepted an AROM although I can no longer remember why (which bothers me a bit...) but anyway I was laboring well although contractions were incredibly intense.  My son's heartbeat stayed steady throughout labor but after the AROM there were significant decelerations to the point that my midwives gave me oxygen and told me to get up on the bed (I had been on the birth stool).  A significant side-effect of AROM is that cord compression is more likely to occur causing fetal distress.  Without the bulgy bag of waters for protection the baby is less protected and more subjected to the rigors and stresses of labor.  Since my son could no longer tolerate the contractions and pushing as well, I had to be up on the bed and slow things down in order to proceed safely.  If I had left my bag of waters intact would labor have continued as steadily but with less distress for my son?  It's possible...

My third and final example is from a birth where the baby was actually born in the sack.  It was my client's first birth, and everything was progressing steadily and normally.  The doctors were very gentle and patient, encouraging my client and remaining calm and steady throughout.  An ideal situation!  Whenever my client complained of pain or wondered when labor was going to end, instead of offering to "do something" i.e. break her waters to speed things up, offer pain medication, the nurses and I instead offered words of encouragement and gently helped her breathe through her contractions.  The baby's heartbeat never faltered and when pushing time came, my client pushed slowly and steadily with each contraction.  We all expected the bag of waters to break explosively on any or all of us there assisting but it never did, and in the end the baby was born, beautifully and gently with the bag intact.

Expecting labor (especially a first labor) to be slow and steady and allowing for pushing to be slow and steady as well is key.  Avoiding stress for mother and baby is also key when aiming for a natural childbirth.  Looking back, I think what I needed most towards the end of my first labor was encouragement that I was doing well and that all was proceeding normally.  To me, my labor seemed abnormally slow and painful.  I wanted/expected the AROM to be my miracle pill, dropping my baby out of me quickly.  That didn't happen and afterwards I still remember feeling that there had been something wrong or abnormal about my labor and my experience of pain.

Birth is difficult but shouldn't be scary.  When a laboring woman expresses pain or fear the best thing her caregivers can do for her is give her a sense of her own power to birth.  How this is done varies woman to woman.  Some need words of encouragement and praise.  Others need to do something, so suggesting position changes can be really helpful.  Others like touch, so massage or counter-pressure can give them the boost they need to keep going.  Offering to break their waters or offering any other intervention even when needed should be done carefully and considerately since it carries with it the implicit observation that whatever the woman is doing it is not working.  And equally importantly, breaking the waters should not be touted as a safe effective way to speed up labor.  It can speed things up but it is not always safe or the most effective way to do so.  The potential risks should be adequately explained and it should be suggested only after other methods have been tried.

Tuesday, March 3, 2015

Maternal Mortality in the U.S. a True Health Care Crisis

Studies have shown that women-centered care improves outcomes.  Women-centered care should mean that the care is focused on the women and offers consistent quality health-care while being respectful of each woman's unique needs and background.  For me personally, women-centered care means that each woman gets to choose where she gives birth, who gets to be there, and that she receives respectful and quality care from her providers.

In the United States, we may claim that we offer "women-centered care," when in fact the care most consistently delivered is sub-par with less than stellar outcomes.  How can this be, you may wonder, when we are a developed country with the most up-to-date medical technology money can buy?  To demonstrate, I will simply point to the statistics gathered from the United Nations showing that between 1990 and 2008 the vast majority of countries reduced their maternal mortality rates for a global decrease of 34 % while maternal mortality nearly doubled in the United States (Maternal Mortality in the United States: A Human Rights Failure, Association of Reproductive Health Professionals Journal, 2011).  Of the many reasons for this statistic, I would like to focus on the one that I see most often in hospitals today: the overuse of medical technology.

Studies between 1996 and 2008 show that there has been a 56% increase in surgical births, with no evidence for improved outcomes.  In fact, there have been studies showing data that the increase in medical intervention actually increases maternal and infant morbidity.  This is not to say that there haven't been losses due to the lack of medical technology; there have been.  It's just that there are far fewer of those deaths than there are preventable deaths due to in part to the overuse of medical technology than otherwise.  For example, there are countries with less life-saving medical equipment that have lost fewer mothers and babies than we do in the United States.  And the reality is that the United States ranks 50th in the world in terms of maternal mortality.  So while we like to think that we are safe and protected in our hospitals surrounded by the best technology on the planet; we may in fact be placing ourselves in far greater danger than we realize.

I don't mean to sound all gloom and doom, but I do think that an increase in awareness is called for.  The statistics are scary, yes, so rather than argue, let's do something about it!  Some states have already put in place systems to increase reporting so that we can find out more about why these deaths are on the rise and what we can do about them.  There are even a few health care models utilizing fewer medical interventions and their outcomes have been consistently good.  We are making progress, but it is slow.  And here is where I will venture into the philosophical realm.  To quote a Native American saying used most often by environmentalists, "tread lightly upon the Earth, and live in balance and harmony."

In order to improve our obstetric care in the United States we have to start treading lightly.  Birth is not something that responds to a hammer fist of intervention.  Truly, birth works best when it is left alone.  In this instance an encouraging word and a gentle touch will do far more to effect good outcomes than a mighty weapon (forceps, episiotomy) and a take charge attitude.  I've seen too many doctors enter a delivery room and take over the whole scene.  I am here now, and since I am here, I must now do something to get this baby out!  Seriously?!

Again, just to qualify, I do not mean that birth always works best when left alone.  Of course, there are times when medical intervention is called for and necessary.  But when there is no true medical need and intervention is still applied, for whatever reason, that is what I am railing against.  That is where we run into trouble.  So when a doctor says it doesn't matter how the baby is born, you have my permission to say, "Actually it does and you are not following evidence-based practices if you believe otherwise."  Medical procedures should be left for when they are truly medically necessary.  Women should be assured that medical professionals have their best interests at heart.  They should be assured that nothing will be done that might endanger their lives or the lives of their babies.

The really backwards thinking that goes on is that by doing more medical interventions, we think we are preventing complications and death, but that is just not true based on the statistics.  So, to improve care, we need to start paying attention to the data.  It does not pay to induce labor unnecessarily.  It does not pay to do routine cesareans.  Most importantly, it does not pay and it can do severe harm.  It's time we started paying attention to other countries where outcomes are better and try to adopt more women-centered practices here in the United States.

Tuesday, February 10, 2015

Why Dads Rock the Birth Scene

Hold tight, I'm going to get around to the topic of this post but first I need to go on a round-about to get there...

Women were designed to birth--physiologically speaking we all know this to be true.  I remember an old psychology professor of mine lecturing on how women were much stronger than men.  Although men possess the bigger muscle groups, women have the stronger immune systems.  We were designed to survive.

Following this topic, I think it interesting to note discrepancies in popular thinking.  For instance, most people would say that women, girls in particular, need to be made to feel their value and given every opportunity to be told they can do and be anything they want to be.  If you were to say the same about men, boys in particular, most people would dismiss it as unnecessary.  Aren't boys already too inclined to think themselves masters of their own destinies?  Don't they already have every advantage over their less powerful girl counterparts? 

I read a book that cited recent studies showing the reverse to be true.  Girls, for the most part in our country, do grow up feeling that they are valued and in fact are more apt to raise their hands in school and go on to higher education.  Boys, however, are less inclined to raise their hands, are blamed for more disruptive behavior in school and are nowadays less likely to go on to higher education.  So, where does all this popular thinking come from?  Or are we just operating on outdated information?

What does all this have to do with birth?  Well, I think there has been a subtle shift over the years following the Women's Right's Movement.  Again to quote my professor, whenever an extreme occurs i.e. women being treated as second class citizens, an extreme response is generally called for as a corrective.  However, on the road to finding balance it is often necessary/inevitable to swing out to the opposite extreme before you are able to settle again.

I think rather than belittling or undervaluing women, these days there seems to be more belittling/undervaluing of men going on.  Watch any television sitcom.  There is almost always a quirky/beautiful/smart woman followed by a sweet/ignorant/less capable male counterpart.  Getting back to birth...watch any show and you'll see the husband break into a cold sweat and then invariably pass out just as the baby is about to be born.  The exasperated women just rolls her eyes and gets down to the business at hand.

So, to question popular thinking.  Is this really true?  Since allowing men to be more involved in birthing, have they proven themselves to be more of a hassle than a help?  In my experience, as above, the reverse is true.  When given the right tools and support, men totally rock the birth scene.  Here's how the situation typically goes:

I (as the doula) meet with the dad-to-be and give him a rundown of events.  He tries to look interested but continues to hold with his private convictions which are that he'll be there to hold her hand and run for ice chips but he won't be doing much more than that.  I smile, because secretly I know the truth.  Once labor starts, I arrive to a scene which usually involves a very active dad running around to make sure there's food and everything packed.  Then while labor gets more intense, he stands for hours in a cramped position to keep his wife comfortable.  He gives steady counter-pressure.  Wets wash-clothes.  Holds steady as his wife hangs on to him for support.  He doesn't complain once that he needs a break or could use some food/rest whatever.  His stamina rivals his wife's...it seems to be fueled on the feeling of, "if she can do this, the least I can do is stand by her."  And he does.  The coolest part for me usually comes at the end where the dads who were most vehemently opposed to watching the baby be born (I'll be standing at the head of the bed thank you very much!) are actually the ones most excited, overwhelmed, awed by the whole process that they are right there to see their baby be born.  It is an awesome moment.

So, don't get suckered into believing popular thought without at least testing the waters first.