Dear "Sarah": There IS Hope for a Better Birth!

Sarah,

When I read your email, my heart went out to you. I know of so many women who dread to think of having another baby... because of the trauma of labor and birth. Some of my friends, even though they've wanted another baby, have told me that they've cried to see the little pink line appear on their pregnancy test, as reality hit them and they knew that once again they would be subject to a overwhelmingly painful labor in a few short months.

I can't promise that this birth will be different for you, even if you do everything suggested. Some women have relatively easy births. And some women have agonizing births. I've learned over the years, it's not all about whether the woman is a wimp or not or whether she thinks positive thoughts, or whether she just hasn't yet discovered the pain coping technique that "works for her."

You are absolutely right. Some of the most painful and overwhelming labors are those that happen so fast. Women talk about 12 or 20 hours of painful labor, and then say, "What?! You got away with 2 hours of labor?!" In reality, what most of them don't realize is that many times a 2 hour labor is just like compressing the 12 or 20 hours that they experienced into a fraction of the time. So, yes, it is often even more overwhelming, relentless, and excruciatingly painful. There is not magic solution to slow your labor down and let it hit you with the normal intensity that most women experience, but there are certainly some things that you can do to make it a better memory.

Some women try everything and still, they have miserable labors and/or births.

For many women,

Getting prepared is good, but it doesn't fix everything.

Being well-supported is good, but it doesn't fix everything.

Being in the right environment is good, but it doesn't fix everything.

Neither does trusting your care team,

or being in water

or being upright

or being in bed

or planning to "just ask for pain meds"

or listening to music

or being at home

or being in the hospital

or eating handfuls of Vitamin C tablets

or overdosing on Calcium and Magnesium in labor

or eating more beans during pregnancy

or the hundred other things that friends, magazines,
websites and other helpful people will recommend!

Sometimes you do everything right (I'm not implying that all of the above are "right" or a good idea) and STILL your birth is a miserable experience.

But I can offer you hope. Rarely does a women come to birth well prepared, well supported, choosing the right environment and the right care provider for her situation and still hate the way it turned out.

A friend of mine who I'll call Susan has had 8 children. They've all been hospital births, mostly with epidurals. One was a forceps delivery that damaged her son's spinal column for life. One of the middle kids was a c-section for an emergency that arose in labor. She has polyhydramnios (too much amniotic fluid in pregnancy) and she has borderline gestational diabetes. Sometimes her doctors control her diabetes with insulin, sometimes she controls it with diet. She's been induced for part of her labors. Other times she's labored naturally for about 24 hours before making little progress and succumbing to an epidural.

Susan has talked about how horrible birth is for as long as I can remember. As a teenager, my mental picture of birth was partly painted by the things Susan would tell me about her births. I shuddered to think that birth had to be that hard and that for her, the only saving grace was an epidural.

When she became pregnant with her eighth and last child, I had recently taken some doula training, and offered to be at her birth. With very little experience and only a stack of books to loan her, she began unloading on me the full horrors of her past birth experiences. She explained how she never goes into a normal contraction pattern once she gets past about 5 centimeters dilation. She said, "The doctors always come in and look at my fetal monitor strip and say, 'Wow. You don't do contractions like most women. You just have one long contraction till you start to push.' "

She explained how her contractions all melt into one, and she only gets a short break of a minute or less every half hour or so. "So, you see why I can't do it without the epidural," she explained. I totally understood. If I had one long contraction for 48 hours, I'd be begging to get signed up for the epidural as well! I felt very powerless to change what her body does to her. After all, this had happened seven times now, right?

But I encouraged her to work towards what she wished her birth experience could be, even if it wasn't likely to happen that way. She began reading books on Natural Childbirth and for the first time in her life she was saying, "Oh, I wish my labors were normal so I could do them without the epidural...." She really did want a natural birth, but she felt that would be absolutely impossible in her situation. Nevertheless, she prayed desperately that somehow this baby would be born differently. My dear friend had endured 30-40 hours of torture with other earlier births before getting the epidural, and saw no point in doing that to herself again with this one. I didn't disagree with her decision, just tried to be supportive.

The day came when she wondered if she was in labor. We headed to the hospital to see. Contractions were regular, but not very painful or strong. Things were most likely just putsing around. The doctor gloved up and reached for the cervix, when his eyebrows shot up.

"Oh, my!" he exclaimed. "Have you been doing this labor for awhile?"

"Well," she said, "Kind of all day, but I pretty much ignored it and went on with my work because I had a lot going on."

"Well, you're going to be happy. You're a stretchy 7 centimeters!"

Now we looked shocked. She the most shocked as she stammered, "I've never experienced 7 centimeters without an epidural! Never! I've never been able to handle it by the time I get to 5 centimeters. Usually by then I'm climbing the walls with pain, and there is no break between contractions! And usually by the time I get to 5, I've been in labor for at least 24 hours!"

An hour later, Susan was sitting on the birth ball, still smiling and talking between contractions.

An hour later, after the doctor broke her water, she was declared completely dilated and ready to push with her next contraction. Things were getting intense at that point as she was in transition and crying, "I can't do this. It hurts so bad!"

Then for ten whole minutes, her husband, the doctor, the nurse, and I just stood and waited for a contraction that didn't happen. Susan kept looking around the room and saying, "This is so weird. It's surreal. Is something wrong? Why am I not contracting anymore?"

The doctor wisely smiled. "Oh," he said, "Sometimes this happens. It's usually just your body giving you a little break for what's ahead..."

Soon the contractions resumed and she set to work pushing, which she had never experienced without an epidural. Even though she could feel what she was doing, and was being more effective that her usual pushing, she hated the feeling. Fifteen minutes of pushing, a few screams, yelps, blowing and breathing, a few more,"I can't do it's" and "Yes, you can! You're moving your baby down" later, she had a chubby pink baby girl in her hands.

Sobbing, and panting she looked over at me and said, "I don't know how that happened like that! I can't believe I just had a baby like that! I wanted a natural birth. I never thought I'd get one, but I did! God is so good!"

Years later, she still talks about her birth to almost every woman she meets, telling them that birth isn't always bad, and there is always hope that you can have a "good" birth, no matter how many miserable experiences you've had.

She's asked me over and over again what it was that I did for her to miraculously change her birth experience. I have told her over and over that I honestly didn't do anything except answer her questions, breathe with her, get her extra pillows, and show her husband where counter-pressure felt good on her back during labor. I didn't do anything special, but her body obviously did a totally new labor pattern that she had never experienced with her seven previous babies.

I don't know what happened or why that birth was different. All I know is that her last birth radically changed her life. Instead of feeling helpless and at the mercy of a "dysfunctional body," she's never forgot how empowered she felt to push out her own baby and to see her body work perfectly fine.

I wish for you the same miracle.

In the meantime, though, I suggest that you do everything you can to prepare for the birth you've always wished to have.

I recommend an experienced doula as #1 on your list.

When you are experiencing overwhelming contractions, it makes all the difference in the world to have someone there to walk through each one with you, and keep you centered, helping you to stay on top of the pain. Of course, husbands are great and it sounds like your husband does a great job helping you through labor, but they can also be so emotionally pulled into your pain that they can't focus on your need in the same calm, reassuring way that a motherly doula can. It is optimal to have one person there to focus on whatever you want physically (back pressure, massage, cool washcloth for your forehead, etc) and one person there who is going to stay right at your face constantly during every contraction, watching your every facial expression, and listening to everything you do so that they can totally focus on where you are at "in your head" and walk you through the contraction one at a time. Find a doula who is experienced and has attended at least a few dozen births in that role. Someone who you feel comfortable with and can trust. Many doulas are certified through ALACE (http://alace.org/) or DONA (http://dona.org/), but other very good and qualified doulas have attended hundreds of hospital births, but have never been certified. Interview them thoroughly. Who do you like? Who seems to understand how you feel about birth and what you wish could be different? Who do you feel completely comfortable with?

My #2 recommendation would be to evaluate whether your birthing location and caregiver are appropriate and best for your situation.

You may have always went to the hospital and used an obstetrician for your births, but perhaps your situation would be more appropriately handled at home with an experienced, well-trained midwife. That is a decision that you will have to make, based on lots of research and reading. Of course, you may be a person with certain risk factors that makes a hospital birth a necessity. If so, or if you just aren't comfortable with a homebirth, then make sure that you have the best doctor (or hospital based CNM) and hospital for your particular situation. Is your doctor committed to helping you have the best birth possible? Is s/he sensitive to your wishes and needs during labor and birth? Do they adhere rigidly to protocols and procedures that are typical, but not evidence-based? Will your doctor allow you to labor in whatever position/use whatever comfort techniques are helpful to you?
Many people think of homebirth as more "risky" than typical hospital birth. It can be when not done right or not properly attended. But when properly attended, it can actually be safer for healthy, low-risk women. I encourage you to do your research carefully. All of the quality homebirth studies show that planned homebirth (when attended by a well-trained midwife) is equal or safer in outcomes for mothers and babies, with far less interventions like c-sections and forceps/vacuum delivery. Of course, there are things that can occur at home that would be better handled in the hospital, because they have the technology/machines to deal with that particular situation. But, on the other hand, there are many situations that occur in the hospital (think: under staffing, more medical errors, infection rates) that would be more safely handled at home. The risk factors for home and hospital birth are different. But that does not mean that there are more risks at home for healthy low risk women attended by experienced, knowledgeable midwives. If, after much research, you decide that homebirth is for you, do some more research and talk with your midwife about the possibility of water birth. Obviously, it's not for everyone and benefits and risks should be carefully considered. But, for many women who have really intense, painful births, having a water birth makes all the difference in the world to them. Waterbirth International (Barbara Harper, author of Gentle Birth Choices) offers lots of resources in this area.

There are many, many ideas out there for reducing the pain of labor. Some of them have been suggested in the comments section of the previous post. Many of them have not been mentioned on this blog. As I find time, I will post more ideas for you.

Regardless of who you decide to have deliver your baby, and where you decide to give birth, I hope that you will think it through carefully and research your options. Birth is never something to be taken lightly. On one hand, it carries with it a life and death responsibility, and on the other hand, it can be the most joyous, beautiful day of your life!

Plan for your birth to be better this time, know that it can be, and then take steps towards making that happen!

And whatever happens, I applaud you for your bravery to experience natural, unmedicated childbirth to give your baby the best start possible. You are among the bravest 10% of American women who experience labor with no pain medication!

Ten Centimeters. Push!

Last week I found myself in one of my favorite positions -- Leaning over a hospital bed, rubbing the back of a laboring mother.

Over all, the labor wasn't bad.

I went in with a positive attitude, hopeful of seeing a good birth. I liked the obstetrician - she was an extremely nice woman with a great personality, and seemed to genuinely be enjoying her job. She was very supportive of the mother's desire to have no epidural if possible. Although medical reasons made the obstetrician decide that induction of labor was appropriate, she respected the mother's wishes to keep the Pitocin drip at a minimum and not turn it up once she started contractions.

The mother had given birth in the same hospital twice previously and was well prepared for labor. Her husband was supportive and as helpful as possible.

As labor progressed and the Pitocin induced contractions became more and more unbearable and on top of each other, the nurses were awesome. They provided one-on-one care, basically having someone in the room with us constantly. They, along with the father and I, encouraged the mother to try all sorts of positions - standing, hands and knees, sitting on the birth ball, rocking, etc.

I was even more impressed when the nurses got into whatever positions they had to to continue to monitor the baby's heart rate. It seemed that whenever the mother was in an upright position, the electronic fetal monitor (EFM) just wasn't tracing the heartbeat very well. So, the nurse had to stand there for several hours continuously holding the doppler in place to maintain a tracing. There was absolutely no "I'm really busy. You'll just have to lay in bed so we can get a decent tracing" or any, "I'm sorry this isn't working. We're going to have to put in a fetal scalp electrode." (The obstetrician wanted constant monitoring because of an increased risk of fetal distress with the Pitocin induction.) Care was all focused around what the mother wanted and needed and what made her most comfortable.

I was also impressed with the information that they provided the parents with before taking any action. The mother got vaginal exams when she wanted them, not every two hours or according to any set protocol. The father and mother both didn't want her water broken early in labor. The hospital staff respected their decision and didn't do it till near the end, when the mother requested it.

As I massaged the mother's shoulders and gave the father suggestions for new ways he could support her and asked the nurses to better explain the progress to the couple, I found myself thinking, "This birth isn't bad. It's about as good as hospital birth gets."

Of course, the Pitocin made things miserable for the mother, and more than once she just burst into tears and cried, "I just can't do this anymore!" But every time she got to that point, we managed to re-focus her on dealing with this contraction and just getting through right now. Her obstetrician poked her head into the room at just such a moment, and very quietly, almost reverently watched her experiencing an intense contraction. "Wow," she whispered. "You just never see women willing to do this any more. I'm so impressed."

Ten centimeters came as the sun came up. The shift would be changing soon, but these nurses were excited that they would get to see the fruit of this labor before they left. The doctor was summoned. Mother got back into bed and was positioned in a semi-sitting position. The bed was broke down, and her legs were spread apart while the overhead lights were turned onto the site of action. The doctor gowned and gloved. Two nurses held one leg (since the stirrups were uncomfortable) and I held the other. Sterile drapes were placed everywhere, leaving only the vaginal opening exposed. The father, nervous and excited at the same time, held her hand, and reassured his exhausted, tearful wife that she was almost done. She was so tired, and kept saying, "I don't think I have the energy to push. I can't."

We all assured her over and over that she could and would get her baby out. The doctor leaned in close to her face and looked her in the eyes, "Just listen to me and do what I tell you. Just follow my instructions closely and you'll be just fine."

The mother nodded through her tears, and the father whispered, "Honey, you can do it. Just listen to the doctor."

"Okay, on the next contraction...." The doctor began to explain the process of letting the contraction build, then taking a deep breath and holding it while pushing as hard as possible while the nurses count to ten.

I sighed to myself. Purple pushing. Why do all doctors think that this is the only way to get a baby out? I knew they'd do this. Why do I even hope that this time will be different?

("Purple pushing" is the above described technique, termed such by many doulas and midwives because the mother has so little time to breathe and exerts herself so intensely that she often starts to turn purple and even burst the blood vessels in her eyes. It has been employed at nearly every hospital birth I've ever attended. It barrels a baby a baby out faster than any other method of pushing. A first time mother who might take an hour to push a baby out when allowed to do it at her own pace, will usually push a baby out in less the 20 minutes with this incredibly intense way of pushing. I personally think that purple pushing can be necessary and effective if a baby is in fetal distress and there is a good reason to get the baby out as quickly as possible. If there is not medically indicated reason, I think it just traumatizes the mother's body [tissues don't have much time to stretch and she's more likely to tear, etc.] more than necessary, not to mention that she thinks of pushing as one of the hardest, most exhausting things she's ever done.)

So, the pushing began. "Take a deep breath. Hold it! PUSH!! One.... two..... three..... four.... no, no, don't take a breath yet! Keep pushing down and out as hard as you can!... five.... six... that's a girl!... seven.... eight... nine... TEN! Good push! Now, quick, quick, another deep breath, and down and out! One.... two.... three.... "

(Mother falls back exhausted. "I can't! I have to catch my breath! I can't breathe! Just let me catch my breath!")

"No, honey. Not till this contraction is done." (Pulling her forward) "Take a deep breath right now, and hold it. Hold it while I count to ten... (more insistently) ONE! TWO! THREE! FOUR...."

Ten minutes have passed. We're seeing a baby's head. The doctor comments on all the hair. Mother is gasping for air between pushes and saying she needs to slow down. The Pitocin drip is still going, and the contractions are coming right on top of another.

"No, not till your baby's here. Keep going!"
The nurses get in her face to help her stay with the pushing a little longer. I want to tell her she can take a 10 second break, but that is obviously not the opinion of the doctor.

I tell myself that this is ridiculous, but determine to keep my mouth shut. I'm the doula, not the obstetrician. The doc keeps taking sideways glances at the monitor. The baby's heart rate shows no sign of compromise. It's plugging away with nice short and long term variability around 140, even during contractions with head compression. Wow! The doctor smiles, "Your baby is doing great! Let's hurry up and get him out!"

The contraction ends. Mom falls back on her pillow and sobs and gasps for air. "Just... just let me rest for a minute..." I'm happy to see that the contraction is over and baby is wonderful. Surely they will let her rest till the next contraction hits. The father looks slightly concerned, torn between wanting to help his wife get what she says she needs, and wanting to follow the doctor's orders for the safety of the baby.

But, no, rest is not an option. The doctor wants to get this kid OUT! "You're almost crowning! You can't stop pushing now till your baby's head is out," she says firmly. The mother wearily sits forward, clutches her thighs again and pushes.

"No, harder, longer. Take a deep breath. Hold it while we count...." And again.... and again.

Finally a head emerges.

I breathe a sigh of relief. Finally the mother will get to inhale once without holding her breath for the count to ten.

I wait for the doctor to feel for cord around the neck. Instead she graps the baby's head firmly, locking her fingers under it's jaw line on both sides, braces her feet against the base of the hospital bed, and leans back, pulling for all she's worth. "PUSH!" she shouts at the dazed mother.

I watch with horror. The baby hasn't even rotated! How does she expect to pull the little guy out without allowing his shoulders to properly spiral through the pelvis?

The baby doesn't pop loose. Her eyes register panic. I see "lawsuit!" flashing through her mind. She yanks a little harder on the head. Still no baby. "Stuck baby!" the doctor half whispers severely to the nurses. The father has realized that the doctor is frightened and something is dead wrong. Tears squeeze out of his eyes.

"Supra-pubic pressure!" the doctor shouts in the direction of the nurse at her right shoulder. There are four nurses and a respiratory therapist standing by. Three of the nurses dive for the mother's stomach. (Supra-pubic pressure is usually applied with the palm of the hand, pressing down hard on the top of the pubic bone, trying to help the baby's shoulder "pop" out from underneath. It's a maneuver used for shoulder dystocia.)

One nurse lays the bed back flat with one swift maneuver. The other three pile onto the mother, leaning all of their weight into her stomach. She screams. "PUSH!" everyone yells together. "HARDER! HARDER! You've got to get this kid out!" The mother again grips her thighs, now having her knees almost to her ears and pushes with every ounce of strength she has left.
The doctor leans back and with all of her 200 pounds, pulls on the baby as if her life depended on it.

The baby pops out. It's been less then 15 seconds since the head emerged. The doctor quickly grabs a hold of the pink, squirming body of a crying baby and suctions and cuts the cord while uttering a sigh of relief. All that scare and an APGAR of 10. The nurses straighten up, slightly shaky. The parents can't stop crying and shaking. Their little boy is here, but his arrival was the worst minute of their life.

I stand there, still holding the mother's trembling leg and rubbing it and thinking...
About how this birth happened. About how it could have happened differently, if only some common sense had been used and everybody hadn't been in such a rush.

I replay every move over and over. It wasn't a shoulder dystocia. It was a little 6 lb. baby, being pushed out by a woman with a more than ample pelvis. If the baby would have been given another 30 seconds to rotate and line up the rest of his body, he would have slid out with the next push.

I shake my head, feeling sorry for the obstetrician who created her own emergency and is still shaking about the "close call" she had.

I feel most sorry for the mother and father who just went through some of the scariest moments of their life as they welcomed their baby.

The obstetrician tugs on the still pulsing cord, pulling out the placenta and throws it into a basin for pathology to inspect. She asks the nurse to turn the Pitocin up (to keep the mother from bleeding), and then inspects for tearing.

Seeing none, she looks pleased. It's been almost 5 minutes since the baby was born. He is wailing in his little warmer next to the bed. The mother is too exhausted to want to hold him right now, so the nurses are playing with him. The doctor pats her patient on the leg and says, "You look great! You'll be a little sore. Just use ice packs for a couple days. Congratulations! You have a beautiful baby!" She breezes out the door, to deliver the next patient.

I like her. She's a nice, caring woman. She's sweet and friendly. The nurses were great.

But now I know why I don't want a hospital birth. Sometimes I forget.
I'll remember this one for awhile.

How much do nurses learn about natural birth?

A week or so ago, I heard from my friend, "Julie". She's a newly trained doula, finishing up her certification and has been attending births since last summer.

Julie had been invited to speak to a nursing class about the role of a doula* in the delivery room, and comfort measures that can help women cope with the pain of labor. I was excited for her and hoped that she would be a part of helping this whole class of nursing students understand and promote natural birth. I was shocked when she emailed with a report of how it had went...



"The nursing speech went well. I was surprised to learn that even though it's a maternity nursing class, the students never see a mom in labor, never do any type of labor support. Their clinicals cover newborn tests and postpartum work - not actual labor work. The professor said that she has to cover IV medications and epidurals because that's what's on the state exam. They don't have time to work on other comfort measures. It was hard to relate my info to the students since they've never seen a labor[and] can't fathom why anyone would do it without pain meds...
When I mentioned that they can really set the tone for a labor and can really influence how a mom feels, there were lots of nervous giggles. When I said something about how moms look to them for reassurance that everything is ok and that many moms feel like the nurse is in an authority position -- they actually looked panic stricken!
It puts the nurses in a slightly different perspective for me. Maybe they aren't anti-natural birth as much as they just really don't know what to do [for a mother attempting a natural birth]. They aren't trained in it at school."

These are RN students, getting a 4 year nursing degree from what is considered a top nursing school in the midwest. This class is the Maternal/Neonate one that everyone is required to take.
Julie learned that their clinicals include coming in as a women is in the final stages of pushing, just in time to do the baby's Apgar scores, weight, etc. They also do the next day post-partum vitals for the mother (blood pressure, temperature, etc).

They are not required to have any hands-on experience with a laboring woman. The actual non-pharmacological labor support, what happens during labor, etc. is one or two class periods. The professor said that she has to focus on pain medications, when to give them, when to wait, who can have what, etc. because that is what they will be tested on during their state exam. When asked about other comfort measures for laboring women, the professor told Julie that the text book does a "nice job of explaining" comfort measures.

Makes me wonder how much birth - natural or medicated or surgical - the average nurse has seen when she finishes her nursing degree and graduates as an RN! Any nurse readers, please chime in with comments and let me know how much birth you had experienced when you finished nursing school!

Maybe I shouldn't have been so shocked a few years ago when I was working as a doula in a small town hospital, and labor quickly picked up for my client. Before we knew it the mother had gone from being 3 cm dilated to 10 cm and pushing in less than 30 minutes - and the OBs had all gone home for the night.
The young labor and delivery nurse who was covering my doula client for the evening started to scream, "Noooooo! Don't push! You have to hold it in for the doctor! I can't catch a baby! I don't know how! Don't do this to me. Nooooo!" She looked positively terrified, and was visibly shaking.
She didn't catch the baby - he landed at the end of the bed, and she still shaking, picked him up and said, "Well, I guess he's okay." Then she looked at me and said, "This is my first birth as a nurse."

I was shocked. Maybe I shouldn't have been.


* A doula is a professional labor support person who stays with the mother through labor to provide physical and emotional support.