Thursday, October 26, 2006

The Rest of the Story

Some bug caught up with me over the weekend. I stayed home from work Monday and part of Tuesday to rest. My client was scheduled to be induced Tuesday evening, but had contractions during the day such that her doctor was fine with waiting to see if labor started on its own. It did. Her water broke in the evening Tuesday. She called to tell me while I was knitting and contemplating an early bedtime.

She called again at 11 p.m. from the hospital to say she was being admitted. She was 2 cm. dilated, but contracting regularly every 6-7 minutes. They didn't want me to come yet. We left it that they would call when they were ready.

Her partner called at 2 a.m. to say they were ready for some support. I arrived to find the mother on the birth ball, contracting every 3-4 minutes for about 30 seconds each time. She was serious, vocalizing with the contractions, and talking little in between. In short, she was laboring well and actively.

This couple was very committed to a natural birth for this, their first child. When the mother expressed some frustration on the ball, I suggested the tub as a change of pace. She liked that idea. After having several contractions on the toilet, she got in the tub where she relaxed completely. Her reactions to her contractions changed. She was more vocal and expressed more doubt. She prayed for strength and mercy (my words not hers).

After the tub, we went back to the bed. She knelt on the bed and leaned over the back of it. It was the wee hours of the morning. She was tired. Because she was so relaxed between contractions, it was hard to tell if she was dozing or not.

She was 4 cm. by 4 or 5 a.m. She had asked not to be told her "progress." Instead we said what great work she was doing, assured her that she was making progress and proceeded with laboring. She spent much of her time on the ball, leaning onto the bed. Some contractions she leaned backward into her partner, who was on a stool behind her. She remained extremely limp and relaxed in between contractions. At one point, she was slung back into her partner's arms, her head lolling off to the side and her arms draped wide to either side. She looked more like someone passed out at a college party than a laboring mother -- all the more ironic because this woman is extremely religious and substance avoiding!

Her mother arrived around 6 a.m. What a boon. This was a woman who believes in natural birth and did nothing but encourage her daughter. We all should be so lucky. Her presence energized the room. The laboring mother was working extremely hard at this point. She was non-verbal. She got shakey and had some contractions on the toilet that she grunted through. A check showed that she was 7 cm. dilated and had moved the baby from -3 to -1.

Shortly after that exam the baby's heart-rate lowered to the 100s and the 100-teens. After several position changes, it settled in the high teens with the mom on her side. For a while they were giving the mother oxygen, but it didn't make a difference in the heart rate, so theys topped. They also started IV fluids because the mother was very dehydrated despite our pushing fluids by mouth.

She began to have very bad back labor (my arm is only starting to get sore as I write!) and we entered a time of constant pressure on her back, as well as constant encouragement and acknowledgement of her hard work. She doubted our assurances that it would not last forever. She began talking about feeling pressure, so they checked again.

It had been nearly 3 hours since the last check. Nothing had changed. Ah, plateaus. We all know they happen but they are so hard to face when you've been up all night, when labor is so hard, when you want to be done.

Thankfully the mother was still in the dark about dilation, station, etc., so we continued as we had been. Because of the heart rate, no one suggested moving the mother off her side. Also, she rested deeply in between contractions, so side-lying seemed a good position.

With her water broken, doctors were getting itchy to see progress. They checked her again afternoon. She was still at 7 centimeters, though the baby was now at zero station. She had been in transition-strength labor for more than six hours and no change. The doctors continued to be concerned about the heart rate. It was occasionally dropping below 100 according to the monitors, though it was hard to tell if it was the baby's heart or the mother's they were picking up. The doctors suggested putting an internal monitor on the baby and a pressure catheter into the mother's uterus.

I was getting very discouraged, as well as foggy from my short sleep. I put in a call to T$ to see if she could relieve me. Though I definitely have thought (fantasized?) about it before, this was the first time I'd actually called in my backup. Except the backup couldn't come. She had about one free hour, but then preexisting commitments at home and a spouse who was out of town meant she'd need to leave again. I thought about my options. I could dash home and try to catch an hour's nap. The chances of that were slim -- it's always hard for me to fall asleep after the charged birth atmosphere. I could call in another backup. But my clients only knew T$ and I didn't have anyone else even alerted to my birth schedule. I could stick it out. That was the only realy option.

T$ offered to come once her spouse got home. We left it that I'd call her at that point if I needed to. Before she hung up she said, "Make her change position. Get her out of bed." T$ is the person I look to for an example of how to assert oneself as a doula when you need to. I tend to be more submissive to the mother's needs. I wince at the thought of making a mother move when she has found a comfortable position...even if she's been in it for four hours! T$'s certainty filled me. I hung up, went to the bed, and said, "You're not going to like me, but you've got to get up."

The mood in the room changed. The mother was right on board: "That's right. We've got to get you in a different position." The partner got a second wind. He talked with the doctor and they agreed to use more frequent cervical checks to monitor the contractions' work rather than a pressure reading. The couple declined the internal monitor, after requesting to have their doctr, rather than the resident, come talk with them. Their doctor was fine with that decision.

We gave a few choices and the mother picked the ball. The baby's heart rate actually improved when the mother got upright. After some time, she went in the tub again, on all fours, and found some relief. She got out and labored in bed a while, but became insistant about feeling pressure. Another exam found she was 8-9 centimeters. She avoided the pressure catheter and pitocin and dilated all on her own.

Another hour later she was a stretchy 9 centimeters. She pushed for a few contractions to see if the baby's head would slip past the cervix. It wouldn't. She had a strong urge to push at this point and I raspberried through contractions with her to try to keep her air coming out instead of being held in to bear down.

It was another two hours -- and one or two disappointing checks -- before the mother was complete. By that time, she'd labored the baby down to zero station. We cried, hugged, high fived. They prayed and thanked God. Then pushing stared.

With the mother's first push the heart rate fell to the low 100's. The mother felt constant pain and pressure and was pushing without taking breaks. She was following internal urges completely. The nurse called out "80s" and they turned the mother on her side. The heart rate went up again into the low 100s. The mother took a bit of a breather but then was right back pushing. The heart rate fell again. They put on an internal monitor that pinged like a second-hand. The heart rate was in the high 50s. Suddenly there were about 8 more people in the room. The mother was still yelling and pushing and obviously in anguish. Nurses were talking with doctors were talking with other doctors all deciding what to do. The heart rate came into the 90s. One nurse said, "I am not comfortable being in this room [versus the operating room] right now."

Pretty quickly they decided to take the mother back to the operating room. Unplug, unlock, and away they went with four anxious family members, a doula, and a photographer in tow.

We stood outside the double doors to the operating bays for ten or so anxious minutes. Then someone -- no nurse or doctor we'd seen before -- came out and said the heart rate was up again and that one person could come back with the mother while she pushed. She was going to have to deliver in the OR in case they needed to do emergency surgery. So the partner suited up and went in, taking the photographer's camera with him.

I'm not proud to say it, but I went home at that point. I was not going to be able to help with the birth. Establishing breastfeeding was the next big step, but I did not have it in me to wait until things settled down after delivery so I could help. Not to mention, the hospital they were at has a special team of in-house breastfeeding support nurses who repeatedly visit every mother that plans to breastfeed. I conveyed my regrets to the remaining family, who were very understanding.

When I went to bed last night I still hadn't heard anything. All night I had intense, over-tired dreams of going to visit the family and learning their baby was in the NICU. Or of being at the birth and seeing a silent baby being intubated.

Thankfully this morning the partner called me at work. He said a healthy baby boy was born around 8:00 last night with assistance from the vacuum extractor. Guess what? He was born face up. Yes. A posterior baby.

If this blog were a film, you would now see a montage of scenes:

--the doctor doing and exam and mouthing "no change"
--the mother arching and wailing "Oh, my back"
--the mother on her hands and knees in the tub THEN the the doctor announcing dilation change
--the heart rate tracing showing paired contractions

then me with the word "clueless" overprinted. How could posterior baby not have crossed my mind? I'm not saying we could have flipped him. And she did spend time leaning forward, whether on the ball or over the back of the bed. But I like to think if we'd known, we could have rolled him around and made things go better. On the other hand, we might have only moved him half way... and that could have been worse.

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Friday, October 20, 2006

WIP Saboteur?

During a quiet moment of the mother's labor Saturday I pulled out my scarf for some knitting. Immediately I knew something was wrting. Take a look at my needles.

See how one curves markedly away from the other toward the tip? Closer investigation revealed a broken needle. Nothing a little Scotch tape couldn't stablize temporarily, but a broken needle nonetheless. I reconsidered the carelessness with which I throw my knitting bag in and out of other bags for transport to work and births. Then I felt an irregularity with my finger. Could those be tooth marks?

The back of the needle had matching depressions. It sure looked like someone held the needle in his or her teeth and wrenched it. But who? Who would do that to/with something I left laying around.

Methinks I have a suspect. Yes, definitely a suspect:

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Thursday, October 19, 2006

Corporate Responsibility or Insidious Marketing?

I recently read that Seventh Generation, producer of earth-friendly household items, including unbleached tampons and menstrual pads, is sponsoring the TamPontification Tour. Its purported purpose is to remove the taboo from discussing our bleeding. They probably expect to sell a few boxes of pads and 'pons along the way, too.

I'm torn. In our consumption culture, people take their cues from corporations. If a company says "let's talk about bleeding," that certainly makes it more okay to talk then when the school nurse says the same thing. But it's naive to think that Seventh Generation, however committed the company may be to providing products with the smallest footprint possible, is talking blood for any reason other than to increase sales. It's easier, of course, to see the connection when formula companies provide breastfeeding "Support Kits" to new mothers.

And then this week (though I'm probably late to the party and this has been happening for weeks), I see the Gap has a whole (red) line of clothing, half the profits from which go to fight AIDS in Africa. By all means, fight AIDS in Africa. I love the idea of corporations sharing profits with noble causes.

Remember, however, that by law and definition, corporations exist to make money. It is their raison d'etre. One who is really interested in giving away money sets up a philanthropic foundation or a non-profit organization. The URL ends in ".org," not ".com."

Gap (red) is a dot com. So is TamPontification.

MSF helps fight AIDS in Africa and you don't even have to wear clothes with cache to do so.

All on your own, YOU can help remove the taboo around our bleeding. It's as easy as talking about it. And when it comes to earth friendly menstrual products, reusable pads or keepers are really the best option...


Monday, October 16, 2006

My Solemn Vow

No matter how long it has been since I have purchased yarn,
nor how convenient the store is to my son's karate dojo,
nor how close to my home;
despite the fact that it is the only store in a 20 mile radius to carry Mission Falls 1824 Cotton,
even if I desperately need needles to start or finish a project,
I will not, I WILL NOT, patronize a yarn store that broadcasts conservative talk radio through its store speakers.

It spoils the yarn karma forever and condones the owner's insanity
message of fear and hate
participation in the American Fascist movement

Which I don't happen to share.

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Baby Girl

One of the two clients I currently have had her baby on Saturday. I was getting nervous because she and the other client were both due yesterday. What are the odds of them delivering on the same day? Slim. But increasing with each day that neither delivers.

Anyway, I got a call at 4:30 a.m. Saturday from her husband saying they were heading in to the hospital. Althought this was a first baby, the mother was dilated to 4 cm at her last checkup, so the doctor advised them to head in once her contractions became regular, regardless of how far apart they were.

I met them in triage. A cervical check found the mother at 5 cm. At that point she was uncomfortable with, but breathing well through, contractions. This mother wanted an epidural from the get go. We had discussed a goal of having her be in active labor before getting one. As soon as she was in her labor room, they put a call in to anesthesia.

During that first hour I was with her at the hospital, her contractions picked up considerably. They were coming every 3-4 minutes and lasting 45 seconds. She was having a lot of back labor and working hard. She had an epidural in place by breakfast time and was much happier. "Blissed out" was the term she used.

Then it was the usual waiting game. Fortunately, there were no epidural complications. No slow-down of contractions, no fetal reaction. At some point later in the morning her doctor broke her water. She was 8 cm at that point. The baby was positioned posteriorly.

The baby didn't like the mother lying on one side, so she was limited to her back and her other side. We tried some position shifts and some leg cocking to move her pelvis as much as we could.

By noon the mother had lots of rectal pressure. The doctor checked and said the baby was +3 and no cervix. A little over an hour later, a healthy little baby girl was born.

At the time of delivery, the room contained: mother and father, doula, two nurses (one for mother one for baby), attending physician, resident, medical student (who caught the baby), EMT student and a partridge in a pear tree.

The doctor said before joining his current practice, he was in solo practice for twenty some years. He said he delivered about 25 babies a month. I can't fathom that. Even if he was doing the tradition doctor thing of showing up for the delivery only, that is A LOT of babies to be solely responsible for. And then office visits on top of that. When did the man ever catch up on sleep?

He also said that when he was a medical student, long before the routine use of monitors and medicine pumps, two of his jobs on the OB rotation were to count IV drips to determine the rate of drug administration and to keep a hand on the mother's belly to tell when contractions were starting and stopping. "That is one of the reasons I'm here today," he said to the student. "Once I put my hand on the mother's belly, I didn't want to leave."

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Wednesday, October 11, 2006

We do loves the raspberries

Every fall since my older son was old enough to walk we make one or more pilgrimages to the raspberry patch. Usually it yields enough for a year's worth of jam, plus surplus to throw in (or on) muffins, ice cream and cereal.

I love, love, love LOVE the raspberry patch. For one thing, it is on the most perfect piece of almost-neglected farmland. Old tracktors and trucks decay behind dilapidated barns. A rutted two-track carries you back to the rows of bushes. Aster and goldenrod and timothy invade any open space.

We almost always find surprises there. Once it was a walking stick (the insect, not wood), twice it was tree frogs, another time it was a praying mantis. ALWAYS there are -- oh! -- spiders.

This fall has been wet nearly every chance we've had to go...until last weekend. Oh was the weather gorgeous. Rich blue sky. Gold and red tree leaves. Seventy degrees and lots of raspberries.

While I picked, lifting each branch to see what berries were hiding underneath, my boys ran up and down the rows eating, laughing, utterly relaxed. I was able to lose myself in the simple act of gathering. I thought about wanting to thank someone or something for the day and for being where I was, with whom I was. Not being a deist, I issued a general thanks to the universe for days and experiences like the one I was having.

Then we went home. And sorted raspberries,

ate raspberries,

and wore raspberries.

Then, not satisfied with raspberries alone, we turned to cannibalism.


Monday, October 09, 2006

For your reading pleasure...

Allow me to direct you to the latest installment of Carnival of the Feminists.

And to a review of BIRTH: The Surprising History of How We Are Born.

I haven't read either, I must confess. If you get to them before me, feel free to post reviews here.

I have two clients due next weekend. I'm really hoping one goes early and one goes late!

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Wednesday, October 04, 2006

Cluck, cluck indeed

The Little Red Hen had iconic status in my house as a child. My mother did not read aloud to us often, but I can clearly hear her voice reciting the hen's litany of requests: "Who will help me plant the wheat?" "Who will help me grind the flour?" "Who will help me bake the bread?"

Each time her so-called friends said "Not I," one by one.

Each time the hen said (at least in the version that plays in my head), "Then I will...[plan the wheat; grind the flour; bake the bread]. Cluck, cluck. And she did."

This simple story sums up my mother's world view: You have only yourself to rely on. Others will appear to steal the fruits of your labor if you aren't wary.

At the story's conclusion, the friends want some of the delicious-smelling bread. "Oh, no," says The Little Red Hen, "I will eat the bread. Cluck, cluck. And she did."

Cluck, cluck became short-hand in our family for "Fine! If you're not willing to help, then fuck you." Mom would ask for help cleaning strawberries. Neither my sister nor I would respond. Then mom would say, "Cluck, cluck" and we'd know we'd screwed up. For dessert that night she and dad would have shortcake and my sister and I would watch.

[where is this going, you ask. we're almost to the end]

I was therefore very cautious when I found a blogger who calls herself (and her blog) A Little Red Hen. But the subtitle was "peace, politics, yarnlife after 60." Intriguing.

I've followed her for many weeks now and can report I love the association. I don't know if her attraction to the Little Red Hen is grounded in the same philosophical camp as my mother. They seem to share a certain feistiness. Both are politically liberal and speak frankly. But the Little Red Hen owns vegan cookbooks and asks readers to share how they feel about routine testing for AIDS. Not my mother's style. Anyway, LRH will be joining my blogroll soon.

And for those of you who worry about getting older and falling out of touch with the world, check in with LRH's blogroll. One is the blog of an 85-year-old woman who talks about how foxy she looks in a photo. Another talks about the tatoos she and her daughters (and possibly soon her mother) share.

They are a fun crowd to keep company with and are cheering me considerably on this gray, rainy day.

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Tuesday, October 03, 2006

Last month's Caesarean News

Last month two studies hit the presses. One documented the elevated risks babies born by Caesarean section. The other detailed risks to mothers who deliver surgically.

The September 2006 issue of Birth includes an article by Marian F. MacDorman, who works in the Center for Vital Statistics at the Centers for Disease Control. Her research found that newborn babies were more likely to die when born by Caesarean section than by vaginal delivery. Nearly three times more likely.

The elevated risk to babies was present even when the study population was controlled for pre-existing medical and socio-economic factors.

MacDorman concludes that the hormonal and mechanical process of labor and delivery may better prepare the baby for life outside the womb. She refers to earlier studies that show improved outcomes for babies born vaginally, particularly in the area of respiration:

Labor induces the release of fetal catecholamines and prostaglandins that promote lung surfactant secretion. In addition, epinephrine release during labor, as well as the physical compression of the infant, helps to remove fetal lung fluid and facilitates postnatal lung adaptation. Other risks of cesarean delivery include delayed neurologic adaptation, possible laceration of the infant during the performance of the cesarean surgery, and delayed establishment of breastfeeding.
Babies are not the only ones at increased risk from surgical delivery. In the September 2006 issue of Obstetrics and Gynecology, Dr. Catherine Deneux-Tharaux reports mothers are three and a half times more likely to die if their babies are born by Caesarean section rather than vaginally.

Caesarean delivery brings with it a host of associated complications. Dr. Deneux-Tharaux found that the risk of death was primarily caused by “complications of anesthesia, puerperal infection, and venous thromboembolism.”

Both MacDorman and Deneux-Tharaux situate their research squarely in the middle of today’s debate over rising Caesarean rates. Deneux-Tharaux concludes,

Although cesarean delivery is increasingly perceived as a low-risk procedure, the present study suggests that it is still associated with an increased risk of postpartum maternal death as compared with vaginal delivery, even when performed before labor. This needs to be taken into account by clinicians and women when balancing the risks against the benefits of the different methods of delivery.
Similarly, MacDorman says [emphasis added],

Timely cesareans in response to medical conditions have proved to be life-saving interventions for countless mothers and babies. At present we are witnessing a different phenomenon—a growing number of primary cesareans without a reported medical indication. Although the neonatal mortality rate for this group of low-risk women remains low regardless of the method of delivery, the resulting increase in the cesarean section rate may inadvertently be putting a larger population of neonates at risk for neonatal mortality for reasons that remain uncertain.
For many of women, doulas may be the only source of information available during their pregnancies about these risks. We must see to it that women -- particularly those who have only seen the apparent simplicity of Caesarean birth portrayed in the media -- know that Caesarean birth should be their last resort option, not their first.


Monday, October 02, 2006

The Bump

Am I the only person out there who is rubbed the wrong way by current references to pregnant bellies as "bumps?"

I have had a hard time putting my finger on why I don't like the reference.. At first I thought it was because the worst offenders are celebrity headlines. Apparently it's cuter to ask whether we see a bump on Reese Witherspoon than to ask could she be pregnant.

After more thought today (waiting for the bus, which was late, in the rain) I came up with two plausible explanations for my reaction:

1. Bump is an ugly word. What do we usually associate with "bump?" Speed Bump. Traffic bump. Bump your head/arm/knee. In fact, it's not a far stretch to associate bump with knock as in "knocked up."

2. Pregnant women are infantilized enough without calling the amazing process they're fueling a "bump." After having our first two pregnancies under the care of an OB, we had our third with a nurse midwife practice. At the end of one of my checkups the midwife said, "All looks good. Go ahead and schedule another visit for a month from now." Using the phrase familiar to me from my previous pregnancies I asked, "for a tummy check?" She bristled. "You are a woman, not a two-year old. This is your uterus, not your tummy."

Calling a pregnant woman's belly a "bump" trivializes what is happening inside it. It turns the in-your-face sexuality of a swelling, fertile woman into a mere bump.

Perhaps the good news in all this is that the search for "bumps" is realtively easy. Pregnant women are wearing tight-fitting shirts, sheer dresses, even bikinis. We are no longer hiding our swelling abdomens behind ruffles and baggy smocks.

Now we just need to insist that pregnant bellies be called a beautiful, powerful word. How about...pregnant?

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