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Intervention and support in difficult childbirth

More thoughts on how we give support in a long or difficult labor.

Too often, birthing families are pressed between the policy and the clock. Care providers are concerned with how a labor looks on paper, in the chart. How will this labor look in court? Their concerns overshadow the relationship they have with the mother and the mother is forced to submit to their comfort in their career. Suddenly we hear Dr.s, nurses and midwives yelling or cheerleading.

This very action pushes them further from the mother. They separate themselves from the mother by their perspective of what can she do for them, rather than what can they do for her. Can she hurry? Can she agree to intervention? What will I say at the desk? How will I chart this or write my report?

How can the busy hospital nurse, doctor or midwife support the birthing woman who is experiencing a long and/or difficult labor? It may be that they have to "act as if." They show a calm and trusting face to the woman. They sit down across the room from her and enter in to the rhythm of breathing. They smile, that half smile of contentment with what is occuring.

Of course, I am talking about when labor may be long, but there is no emergency. If you are reading this with strain and thinking, "but what if?" I would invite you to take a deep slow breath and let go of the adrenaline through which you filter birth. Breath in the endorphine state that gets babies out. Adrenaline holds babies in. Why would an entire culture of birth surround itself around the substance known for labor dystocia?



On the other hand, too much help can be distracting, too. The mother surrounded by too many caring people has to filter their words, actions and sometimes, chatter. They prop her up with morale building effort.

There are times in a long labor that a mother may have to go within herself to reflect. So support in a long labor can be required to ebb and flow. Rest is necessary, mentally as well as physically. The support person or people must be able to observe the needs of the mother, before she does, and adjust themselves accordingly.

The father may be present or not, depending on the situation, this discussion doesn't exclude him. The mate, both calm and attentive without asking too many questions, can be the determining factor in whether a woman feels safe to continue a long, challenging labor.

One constant person is often required. If so she needs to be in that midbrain state of the rhythm of labor. The mate may need her presence to model his. He observes and absorbes her calm. He falls into the rhythm of breathing, at least, when reminded.

Sometimes rhythm is missing from the labor, as sometimes happens when there is an asynclitic presentation, even in a calm, trusting laboring woman. Then that calm, mature woman becomes the rhythm. She holds the concept of peace and birth within her eye. Her breath reveals the rhythm, as does her movements and her half closed eyes that gaze beyond the woman.

Two womens' labors and the quality of care

Two women asked me about CPD earlier this week.
CPD is cephelopelvic-disproportion, meaning the baby doesn't fit the pelvis.

One woman was a first time mother working with our home birth midwifery group. She was at the end of her pregnancy with an OP baby. Body work hadn't helped her baby get turned to face her hip or back. The baby hadn't engaged. Being well read, she was now concerned that the baby wouldn't enter the pelvis and a cesarean would then be necessary.

Another woman emailed from the UK. She was pregnant with her second and remembering her first birth. The baby hadn't engaged. She had an early urge to push. Her midwife yelled at her, her words, to stop pushing. This went on and on. An epidural gave relief, but too much, she was put on her back and now had little ability to push when the time did come to do so. A vacuum, or ventouse, extraction was done. She was a bit afraid to hope for the coming birth of her second child.

Our first time mom had a strong urge to push before her cervix was fully opened as well. Instead of trying to stop her, we observed. Later, we encouraged her to push along with the urges. We alternated with asking her to breath through some contractions without pushing. Then, again, she let her body push spontaneously.

Her baby's head needed time to mold, so we asked her not to add to her body's spontaneous pushing. An asynclitic angle (tipped like listening) of the head was a significant factor in the length of time, so we asked her to push. We were exploring what might be the best way to help her. We tried varying how she pushed because this urge went on and on, like the UK woman's labor.

All the time her loving husband stayed at her side, patient and attentive. Her doulas stayed near. Her midwives honored the needs of the birth and introduced a very pointed conversation, gently. By stating that we wanted her to get what she needed, she took that idea around in her mind for a couple of contractions and replied that she was ready to explore what the hospital might have to offer her labor. IV fluids, Pitocin (Sintocin).

In the hospital there were a few more hours until, finally, the cervix was gone. The baby's head had molded enough and the mom's voluntary pushing now became effective. Now she pushed hard enough to realign the plates of California. Her baby was born, healthy and strong.

Both women had difficult births. Both were able to birth without surgery. One woman feels raped. One woman feels empowered.

Penny Simkin says we can't control how labor will go, whether difficult or not, but we can control how we care for women. She was referring to the respect, words and tone we use when talking with pregnant and birthing women. (Postpartum, too!)

I'll add that we can seek to honor the needs of labor, too. The clock is not a good guide for intervention. Giving the woman, in a non emergency situation, time to decide when its time for an intervention (perhaps as a tool for a long labor) considers her needs in the psychological transformation that partuition is. She needs to know her midwives not only hear her, but trust and know the variations in birthing.

Her decision is made not only from her physical and mental state, but made within her support community. She makes decisions among people who are important to her. This is part of her mother-making. A key part.

How the dream birth becomes the real birth is how the dream of her mothering becomes the mothering she actaully experiences. How her support people, including her midwives and doctors and nurses, respond to her needs and how they nurture her changing birth plan reflects on her acceptance of herself as a woman and a mother in her circle.

Choosing transport and an intervention doesn't mean that all her effort is done. There is more effort, more work. Contractions continue and the mother continues to labor. She is brought to yet another level of challenge. The challenge of having thought an intervention would remove effort and finding that it does not. It may help effort, but it does not remove the mother from the work of becoming a mother. She is in the midst of hard work. Work that is rewarded with a conscious connection to her child and to her awareness of the process of mothering.

All mothers deserve to be rewarded in the art of surrendering themselves for the needs of their children. There is not a mother that doesn't deserve our respect for that. Its not a question of the worth and beauty of mothers.

Its a question of how we care for women as they become mothers and the effects of our care on the quality of life for mothers and their babies.

Benefits of volunary licensure of midwives

In an email to a politically active friend here in Minnesota, I said something I'd like to share in general:

I would like to take this opportunity to praise our voluntary licensure for traditional midwives. The voluntary status of licensing traditional midwives in our state protects ALL midwives from:

• Restrictions against helping women with normal birth including OB trends to label as high risks women with a certain maternal height and pregnancy weight gain combination, parity, etc.
• Restrictions against helping women with a variation of normal; such as, weight gain, VBAC, Breech, Posterior (some physicians section women beginning labor/presenting in late pregnancy with a baby in an OP position) etc.
• A monopolization of ideology in practice yet while promoting better practice standards,
• Total adaptation of medical model midwifery because the traditional one faded away under the afore mentioned trends

Should I try for a natural birth?

The first questions you may ask yourself when you are deciding whether you want a natural birth or not, is likely to be,
Can I handle the pain?

Another question is, Is the baby positioned so he/she will fit? Or, simply, Will the baby fit?
(You may be wondering, how can an entire baby fit out that little hole, and what will it do to me?)

The answer to whether you can handle childbirth pain and whether the baby will fit is often the same, single answer. A well-positioned baby leads to a do-able labor and almost always fits the mother's pelvis.

What fetal position is good? Facing the mother's right hip (left occiput transverse, or left occiput lateral) or her back (occiput anterior).

A baby whose chin is tucked before labor will be able to rotate into a good position during labor, if they aren't already in one.

Most posterior babies, in which the baby faces the mother's front (and in my opinion, her left hip, too) will rotate to the anterior during strong labor contractions and then be born vaginally. A few posterior babies will be born posterior, and a few will need medical interventions, like Pitocin or a cesarean, to finish the birth. By far, most babies who start labor in a posterior position will rotate and be born in the anterior position.

For some women with a posterior baby labor will be longer than with an anterior baby. There may be challenges in the labor, such as starts and stops in contractions, clusters of very strongs contractions followed by almost no contractions, and subsequent emotional disppointments due to the confusion such a labor pattern can cause in the parents AND the birth attendants.
See more on posterior labor.


Is that a reason to skip labor and have major abdominal surgery for the birth of your baby?
Here are some other questions to ask:


What do you want for your baby? How do you want your first minutes and hours of your life with your baby? If you knew your second birth would be do-able would you go for it again?

What do you want for yourself? When you look back, what do you want to have learned about yourself? Where do you want to have taken yourself, spiritually, emotionally and physically, with this birth? Is that the place you want to live in?

A doula (doo-la) is a trained woman who will listen to your answers, help you find the truth in your journey and if you want to go with a vaginal birth, or even a drug free birth, she will help you gain confidence and comfort in preparing for and going through labor. I highly recommend finding a calm doula for your upcoming birth.

The New York Times doula article rebutal by Susan Lane

Pamela Paul's article in the Sunday, March 2 Times ("And the Doula Makes Four") left out key points. One is that it's very easy to find out if a doula is certified, because the agencies such as DONA International that certify doulas offer an on-line listing. DONA and the Coalition for Improved Maternity Services also offer a guide for interviewing doulas. Parents should get current references and contact recent clients of a doula they are considering. Ms. Sacher's comment at the end of the article is most appropriate- parents should be conscientious about selecting a doula as well as a physician. Most doulas will meet for an interview at the parents' convenience, making the process easier still.

Minneapolis and the state of Minnesota have more certified doulas per capita than any city or state in the country, and we have wonderful relationships with medical staff in hospitals around the state. The Childbirth Collective is a Minnesota nonprofit organization of doulas, homebirth and hospital midwives, psychologists specializing in perinatal issues, massage therapists and chiropractors with special certifications related to pregnancy, birth and postpartum. Doulas in Minnesota can register with the state, which confirms their certification and conducts a background check for doulas who are then listed on the Health Department website. Most major metropolitan areas have birth networks that can help with doula selection.

I wish Ms Paul had indicated if the doula who disappointed those parents was certified, and if the parents have contacted her certifying agency with their concerns. That would be most helpful to all doulas and future clients in her area.

Finally, given that our cesarean rate is an astounding 31% and rising nationally, and that our maternal mortality rate is rising in direct proportion, and that our infant mortality rate is worse than most industrialized nations, is it really the 1-2% of doula supported births we should be concerned about?

Susan Lane, CD DONA, LCCE, CLC

Minneapolis, Minnesota

salane@visi.com

Birthing in the Field

Hi Gail,

I thought I'd send you a link to my blog where the birth story for Adeline Louise is located www.merfaeries.blogspot.com

The Inversion worked to turn her from breech to vertex but like her sister before her, AddyLou decided to present in the persistent ROT-Posterior presentation, then oddly, she rotated on the perineum so that her face was then fully looking at my right thigh. We had about 45 seconds of shoulder dystocia and then both her shoulders birthed at once. Miraculously my perineum was intact but for skid marks.

...I especially appreciated your website with this pregnancy for all the information and inspiration I found there. Knowing I had an anterior placenta, a transverse baby who moved to breech before vertex, then a persistently "mal" positioned baby was stressful but I took comfort and strength from the information and stories on your site.

While this third labor and birth was longer and more physically/emotionally challenging for me 7 hours to get an 8lbs 10 ounce, interestingly positioned baby out is really pretty good. Not a cake walk, for sure, but doable.

Thanks for all you do!

Brenda Sutherland-Field