· I will sign a waiver that I am/am not giving my baby vaccine at this time.
· I will go with my baby to have his hearing screening done.
· I want to bring my placenta home.
Thank you in advance for your help and consideration!
Ayana’s doctor scheduled an induction for the following week. Spiking sugar levels and insulin were his main concern. Also, her first baby had been only six pounds but this baby was much bigger.
Ayana and I met at the hospital and walked up together. She told me she had just decided on a name, Sisay. She said that in Ethiopian it means “an omen of good things.” When we were settled I filled out the whiteboard in her room: baby’s name, mom’s name, doula, interpreter, etc. The Amharic interpreter who came that day was one of the most amazing women I have ever met. Belem had left Ethiopia and moved to New Delhi, India, six years earlier, all by herself. A traditional Muslim woman, she earned a master’s degree there in business administration before moving to the U.S. She took a course in medical interpreting and got a job with an agency that serves Minneapolis hospitals. This was my second birth with her as an interpreter and we were both delighted when we saw each other again. I had been emailing her and encouraging her to continue her education. Together we are looking into midwifery programs for her. We desperately need women like her in the birth community. She has a heart the size of Texas and is a natural from all that I have seen.
The induction started out slowly. There were mild contractions and Ayana was dilated to two centimeters for the first two hours. I was glad they encouraged her to eat and walk around. By early afternoon the contractions had stopped. It was time for a snack and a nap. The doctor came by and suggested trying some Pitocin next, which Ayana agreed to. The rushes picked up slowly and finally we thought they had gotten into a nice pattern when the nurses saw that they were actually coupling, or coming two at a time with longer rests in between. That occurs when the rushes are neither very effective nor helping the cervix to dilate, so the Pitocin was stopped. The doctor thought Ayana should rest, have supper, and then suggested using a medication called Cervidil that would help ripen the cervix so that either contractions would establish themselves, or if they had not by morning, then the Pitocin might be more effective. Ayana thought this all sounded okay, though it was not in her birth plan. I was glad the doctor was not being more aggressive and actually rather reserved from what I had seen in other hospitals.
By morning Ayana felt much better. Her contractions were regular, though weak. Pitocin was started again. Pretty soon we were in business: four centimeters and she wasn’t laughing at my jokes anymore. This was active labor—serious business. We walked and danced a slow version of a belly dance with me humming along while we bonded with the walls up and down the four halls framing the unit. I suggested different positions: hanging while holding onto my shoulders, leaning into the wall, squatting by the bed, sitting on a birth ball, and hands and knees. We tried the tub for a while, but Ayana liked walking best. Every time we completed a four-hall lap we would go into her room for a potty stop and another full cup of juice. (I am a serious pusher, of juice that is, and not the sports or calorie-free electrolyte versions. This mama is running a marathon here and needs both natural sugars and calories.)
We didn’t need a nurse to check to know she was opening up. The rushes were closer now and Ayana asked for an epidural. I explained some of her other options, but she had had an epidural with her last birth and had written it into her birth plan this time. Although I would love for every mom to explore natural birth, I have a strong commitment to support each one in whatever way they feel is best for them. I can only hope that they will gain strength and confidence with each birth and perhaps consider using less conventional methods in the future. They know I am there for them unconditionally and will not criticize their choices or continue to push in a direction they have decided is not what they want. So I let her nurse know that she was asking for the epidural. She called the anesthesia department with the request and set up the room for the procedure while we continued walking and drinking juice, since I was pretty sure they would not let her drink once the epidural was in place. It is usually ice-chips-only at that point.
Fifteen minutes later Ayana asked when the anesthesiologist was going to come. The nurses assured her he was on the way. Half an hour passed and we were doing some pretty heavy-duty breathing now. At one point I looked over at the nurse who shrugged her shoulders, looking baffled, too. Where were they? Ayana was obviously miffed at this point; she had not planned on this at all. I kept telling her how strong she was and how well she was doing. I helped her rest between the rushes but when each one crept up on her again and then quickly intensified, she repeated her little mantra: “When? When? WHEN?!” Finally another nurse came in and very apologetically told us that the anesthesiologist had been called away to an emergency C-section and would come as soon as possible. I silently wondered why only one anesthesiologist was in the hospital, but I didn’t want to do anything to further disturb our routine at this point, so we continued breathing and resting. The interpreter and I knelt on each side of Ayana, who was sitting in a rocking chair.
All of a sudden she stood up and said she had to go to the bathroom. She had just been to the bathroom so I knew this was the beginning of the urge to push. I was surprised that our interpreter could also read the signs (I knew she was cut out for this business!) and quickly instructed Ayana to sit on the bed where we could help her better. As we got her more comfortable I hit the nurse button and said as quietly as I could, “We are thinking about pushing in room 350.” Sure enough, with the next rush Ayana flashed a look of panic at me and then took a deep breath—as I did—and pushed. And pushed. The doctor ran into the room between two nurses, who were wheeling in the warmer and instrument cart. Another push and we could see lots of Baby’s head. Another grand push and she was born.
Ayana looked down and just sobbed as she reached for her baby, who was already crying. We got them comfortable while we waited for the placenta. Ayana’s look of absolute shock sent Belem into a gale of giggles. I told Ayana how amazing she was. It was obvious that she couldn’t believe she had actually birthed a baby without any medication. We told her it showed how strong she really was.
I found out the next day at our postpartum visit that she is a single mom. Recently divorced, her ex had offered to watch their son when she went to the hospital but had no intention of helping her further. In some larger cosmic plan I believe this birth was meant to be this way to prove to Ayana that she is capable of anything. I think she can now agree, too. I stayed for two more hours to marvel at how beautiful little Sisay was and her newly empowered mother.
“Sometimes the only thing that makes a woman’s pregnancy high risk is her choice of a care provider.”
~Anonymous
Chapter 14: Birthing a Birth Plan
Searching “Birth Plan Templates” on the Internet will garner a myriad of styles, types, varieties, and different interpretations, some good, others not so good, and a few that are downright bad. Throughout my career I have developed what I call my “rule of thumb” for birth plans.
No one will read anything longer than one page. Don’t even think of it! One website boasts “Everything you’ll need . . . ” You’re supposed to fill in the blanks and then print out all nine pages. No one will ever read all of that.
When I am working as a doula I tell the family that part of my job is to be a gatekeeper at their birth. When any new nurse or resident walks in the room, it is my duty to intercept him or her and introduce myself, “Hi, I am Stephanie, Jane’s doula, and this is our birth plan.” That way everyone in the room is hopefully on board and it sends a message that Jane has done her homework and this is important to her.
When a mom sends me her birth plan I check it over and make any suggestions if I wonder about something, like, “Don’t y
ou want to have the baby with you during any exams?” Sometimes I will suggest adding a point or two, or perhaps omitting outdated practices, like being strapped into stirrups. I want to be sure I am clear about her wishes. It isn’t necessary to repeatedly write, “But in an emergency . . .” or “If a C-section is recommended,” because the mom will be the first to know and be consulted if there is a concern.
We need to stay positive and not write in every dire intervention. Yes, we will educate ourselves about what might happen and our options, but we don’t need to expect every such horrific outcome. Another reason to learn about interventions and what options you will have should events warrant is because if you don’t understand what your rights and options are, then you really don’t have any choices; you have decided that you trust the doctor or midwife enough to allow yourself to go into default mode and will do what they feel is best.
A study was done in the U.S. that asked mothers to rate their birth experiences in relation to their birth plans. Mothers (and partners) most dissatisfied with their birth experiences were those who expected every point to be honored by all present at all times. They felt their document was almost cast in stone, and then thought they had “failed” somehow to either live up to their own expectations or that the staff didn’t respect the birth plan (and their wishes) enough and derailed the event from what it could have been.
“Just as a woman’s heart knows how and when to pump, her lungs to inhale, and her hand to pull back from the fire, so she knows when and how to give birth.”
~Virginia Di Orio
Chapter 15: Shoulder Distocia!
I went with Makda to her clinic appointment. The midwives had referred her to an obstetrician because they were concerned that she still had two weeks to go until her guess date and her baby already felt rather large. Another concern was that her last baby had gotten stuck during delivery with a complication called shoulder dystocia. Shoulder dystocia is scary enough that the last midwife made sure to attach an alert to Makda’s chart.
The doctor did an ultrasound and guessed that Makda’s baby, a boy, was about eight and a half pounds, which was what the last baby weighed, though she was only at thirty-eight weeks now. She had two little girls at home, a five-year-old named Qwara and a three-year-old named Retta. They were used to me by now, though remained a bit skeptical, especially since I couldn’t understand a word of their language, Amharic, though they tried to talk to me. The little girls settled on high fives as a greeting and went back to the toy box in the waiting room while Makda and I went into the exam room.
I was impressed that her doctor didn’t rush into the early induction option, especially since the weekend was fast approaching (most C-sections in the U.S. occur before 10:00 p.m. and not on weekends). He explained that since this was Makda’s third baby she should be able to push out another big baby, which she did, after all, the last time. However, he hoped she would go into labor on her own in the next week.
Her husband, Semere, would be staying home with the other children when she delivered, which wasn’t unusual. As mentioned earlier, in traditional African cultures men are not usually in attendance at births, which is one reason our doula group has become so popular with immigrant women. They have aunts, sisters, sometimes their mothers, and girlfriends go with them when they have their babies, but the idea of a doula who can help them negotiate the often mind-boggling American medical system is a godsend to them. In turn, I tell them that I am deeply honored to be invited to be a part of their most intimate moments and made to feel so welcomed at their births.
Makda and I had talked about her wishes, what she liked or didn’t like about her last two births, and together we had written a birth plan. She and I had spent some of our prenatal visits watching YouTube births, especially water births, home births, and natural births. I wanted her to understand her many options. She was especially intrigued by water birth, so we talked about that and included it in her plan.
I could tell the doctor’s words were a bit discouraging to Makda so I suggested that before she left that day we should get the interpreter back and talk about it a bit. I come from what we call the “midwifery model of care,” where we trust that our bodies know how to birth and that they also know how big to grow each baby. The other model of care is the “medical model” that has crept into our collective consciousness and the American way of life for over a hundred years now and, in the process, undermined much of our instinctual knowledge.
Doulas try to find a way to navigate between the two, letting women know their alternatives, encouraging them to find that power that we believe is in each of us, but also stepping back when our sister is on this journey of self-discovery and may not be ready to be as daring as we would be (or wish her to be). We have to respect her choices and hesitations and not show even the least disappointment if she doesn’t choose what we would have chosen for her birth. A doula has to be there to unconditionally support whatever choices a couple feels is best for them.
I told Makda there were a few things that might help her avoid having to be induced, if her baby was indeed ready. I suggested walking a lot, or having sex. Then I told her about Jeannie, who had been told that she needed a C-section the next day and how I had told Jeannie that she could also talk to her baby and perhaps find a way through the problem together. It had worked and she had a vaginal birth without complications. I wished Makda a good night and hugged her goodbye.
Makda called at 6:00 a.m. sharp two days later. She was feeling sick and not sure what to do. She had chills, her stomach was upset, she couldn’t eat, and was experiencing cramps but not contractions. She complained that her back hurt, too.
It sounded like either early labor or a urinary tract infection, though I didn’t voice that. As a doula, it was my job to direct her back to her midwife or doctor and let them decide what to do. I told her to call the clinic and let me know what they thought she should do. She called back to say they wanted to see her at the hospital, but she didn’t want to bring her children, too, and asked if I could call the taxi and meet her there so Semere could stay home and watch their girls. I did so, and soon met her at the hospital.
When I arrived, a monitor was tracking the baby’s heartbeat and another monitor was picking up contractions. She didn’t feel the contractions at all, and her water hadn’t broken. They ruled out anything else that might be causing her discomfort and decided to watch for an hour to see if anything changed. She was one centimeter dilated at that point.
So I visited with her and figured we’d be sent home in the end. An hour later she was actually dilating and the contractions were picking up. We weren’t going anywhere yet. I ordered lunch for her and snacked on what I had brought, though I didn’t have my big doula carpetbag. I hadn’t thought we’d be staying. I was wrong.
Hour by hour she continued to open. Though slow, it was definitely progress. At one point the contractions picked up a bit and she started to feel them, but then they stopped altogether. We walked for a while, glad to finally be able to move around. Her doctor came by later in the afternoon, mostly just to encourage her. He was not in a big hurry. I kept her drinking plenty of juices, which I think got rid of the chills or whatever fever was threatening to appear. Dehydration alone can cause symptoms like Makda was experiencing. By evening, things had pretty much stopped. The nurse called the doctor, who suggested Makda just sleep and we’d see where we were in the morning. I was very impressed with this doctor’s level of restraint.
I went home but assured Makda that I would return quickly if she needed me. I made sure she had my number handy and tucked her in. She had a good night.
The next morning the doctor suggested a very low dose of Pitocin to get the occasional contractions a little closer together. They were still there, but not at all effective. That worked quite well. Finally we entered that point of no return called active labor. With my own five births, I remember thi
s as the moment when you ask yourself each and every time, What could I possibly have been thinking to want another baby and to be back here again? It is the moment when you think, and some say it out loud, Let’s all just go home now and come back and do this tomorrow instead.
One of the resident doctors came to introduce himself and asked permission to observe the birth. Makda didn’t understand what he wanted so I explained that he would like to stand in the corner and just watch—he would not touch her—and learn from the birth, that he was a student doctor and that this is how they learn—and how we can contribute to their education, including natural birth. That is how I learned, I told her, by watching midwives and doctors when I was in school. I explained that she had every right to say no, that there were enough people already involved, but she said it was perfectly okay and even put her hand out to welcome him. He read her chart and asked the senior doctor if, in light of the last shoulder dystocia, he was considering using the Gaskin Maneuver. I was floored! This was the first time I had ever encountered a doctor who not only knew about Ina May Gaskin and the successful management of shoulder dystocia that was named after her, but was actually hoping to see it in action.
Ina May first observed this maneuver by indigenous midwives while visiting the highlands of Guatemala in 1976. The problem of shoulder dystocia has received increasing attention in the medical literature in recent years, probably because of the tremendous potential for litigation that accompanies this disastrous complication. It has been estimated that at least eight percent of malpractice claims alleging fetal damage involve a birth complicated by shoulder dystocia. True shoulder dystocia has been defined as any birth in which maneuvers in addition to lateral traction and episiotomy are required to deliver the baby’s shoulders. The reported incidence of shoulder dystocia is somewhere around one and a half percent of all births. The most common fetal complications include asphyxia, seizures, brachial plexus palsy, and fractures of the baby’s humerus and clavicle.
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