Tuesday, December 18, 2007

Continual Presence at the other end of life


Sitting with my dying niece tonight, I didn't want to leave her. But my son had to be picked up and I hadn't seen my husband in daylight for a while.

We're nearing the final vigil time. It is hard to leave and hard to go back. Each time I approach her home my stomach tightens because I don't know how far she may have slipped away from us since the day before. But there is a grace and a mystery to this that has many correlations to birth care.
Had to come back around to birth, didn't I? Even on the topic of death, I think about birth. Seems natural to me.

Dr.s Kennell and Klaus talked to us doulas about the importance of continual presence: Being with the mother from the time she calls us to her. Most often that is when she has begun early labor. Potty breaks are accepted, but meal breaks are far too long.

I haven't been able to be with Meg continuously. I know I will when her breathing becomes labored and shallow. That is in the last few days. But now is when she needs it. Each moment is so precious. But I can't stop the clock for my family, even for myself.
Sometimes I just got to get outside and walk, or talk with other midwives about anything about the beginning of life, or make a bead for a Christmas gift. I'm a little upset about myself. I have stayed at many births for days. This birth, back into spirit, though, has been months. This level of care, a few weeks now.

Yesterday, Meaghann hadn't said virtually anything all day. Later, as my sister and I dressed her for bed, she opened her eyes and clearly said, "Gail, are you still here?"

How I wanted to stay at her side. But I don't want to, too. She is still independent in her mind and she doesn't have much patience for being fussed over. It can make her crabby with us. Especially if we look worried. I get antsy, want to sleep in my own bed, get something ready for Christmas, or take time for a prenatal or postpartum visit.

Meg has wonderful support, from family, friends and hospice! Her mother is loving and attentive, they've been living together since Meg's 2nd brain tumor, 2 years ago. She has a loving sister who comes frequently; a brother who spoke to her so tenderly tonight. She has help from home hospice, and since Thanksgiving, a dear old friend of mine, Juli Kampmeyer, has come in to give palliative care. In college, we were going to go into nurse-midwifery together. Then, I held a panel of midwives for a community event and from it chose homebirth midwifery, and Juli went into Human Services and then went on a journey that led to home care for vulnerable people, including the dying. She is our midwife. She is our doula.

You readers who are doulas and midwives will have experienced times that loved ones of birthing women ask if you would help them when they have a baby. Well, I actually asked Juli if she would help me when I die.
Dying couldn't be any better than by having Juli by my side. ! Ok, this is the kind of humor you get after months of facing the death of a loved one, and all the earthy practicalities of ongoing care involved with someone who is losing physical abilities.

Meg has someone with her 24/7 now, of course. This 3rd tumor, advanced to a "glioblastoma multiforme," is pressing on her motor nerve and she can't do what she intends to do. Mentally she is often quite cognizant, but she has trouble speaking now. My work as a doula helps me perceive her needs fairly well.

Again tonight, Meg began to talk after a fairly silent day. Her mom teased her about eating chocolate after her teeth were brushed, and Meg smiled her crooked grin.
While being dressed for sleep, Meg's eye caught a decorative plate on the wall and she said, "I love that plate. I gave you that plate."
Kathy and I looked at each other. We haven't heard this many words from Meg for several days! Kathy said, "And I love the giver of that plate."
Quickly, Meg quipped back, "And I love the Givee!"

When later, I told her I had to go, she watched me begin to back up from her bed side. She said, "I love you, Gail."

A wave of sweet emotion hit me like a wave on the beach. A life time of love pours through a simple sentence. Love for your life ahead. It can send you dancing above the pain.

There are many levels in dying, like labor. You can focus on the pain or you can focus on the love. Being one of the doulas for my niece, as she winds down her life, is a walk in God's grace; peace beyond understanding. Brutally tender and surprisingly transcendent.

Monday, December 10, 2007

To try labor if baby is anterior

I've been contacted by a woman in southern Europe who is trying to decide if she should travel to a place where she can labor and give birth or to stay in her city and accept a cesarean without labor. What a position this mother finds herself in! What a dilemma!

Should she put her family into the stress of having her leave their hometown? Will her mate have to leave his work to be able to be at the birth of his child? Who will bring her food and supplements when she is so far away? Where are the women of her community? Will she obtain a vaginal birth at the cost of community support? What gapping hole in society leaves women in this state of childbearing.

Her process of decision making has brought up the question of whether she should try labor if her baby is anterior, but go ahead and accept a cesarean if her baby is posterior.

She has been following her baby's position with Belly Mapping and using some of the techniques in Spinning Babies. She describes her baby as changing from LOP to ROT, and wonders if now at 36 weeks she should book her cesarean.

I have a strong response....

Are you indicating, am I reading you correctly, that you wouldn't try for a natural birth unless your baby is LOT? or LOA? (Click here to see baby positions.)
My goodness, any labor is more likely to progress into a vaginal birth than not, especially if the baby engages by labor. If you do nothing but allow labor to begin and proceed, you are likely to give birth, Paulina!

Help the baby engage by hula hooping on a birth ball or the Walcher's position to bring the baby down. Engagement is more important than OA or OP. Try and help the baby to the left with hands on the right before trying to get the baby to engage. Naturally your baby would engage between 38-39 weeks.
  • Are you doing the Inversion as shown on the little video on my site? Use that one, not the other methods. This relaxes the lower uterine segment.
  • Did you get your sacrum adjusted? This will help the baby rotate now to a left occiput transverse (left occiput lateral) position.
  • A sacrum release by a myofascial person will also help there be more room in the back area of the pelvis.
  • An abdominal release and a round ligament release helps the baby rotate before engagement.

These are the body work things that really seem to make the difference. Oh yes, a pelvic floor release. That last seems to help with any position of baby so the baby can drop. Do that after you do the previous a couple times each. Or do the pelvic floor release in labor. For sure.

Then use an active birth approach to labor. Vertical positions, leaning forward, drug free, eating freely, drinking water and an occasional electrolyte drink, these things, and patience, will help you if you do have a labor longer than average. Don't time yourself, just keep up on food and fluids and emptying your bladder. Love your mate and your helpers and let that love be felt in the room. Have some fun with your adventure. Don't measure it and judge it like it is a fire that could get out of hand. It is a flower opening. Pour a little water on it and get in the sun, or in other words, a nurturing environment.

Think carefully if you would give up on your child's birth. This choice will last generations. You may have a need for a cesarean, but nothing you have shared with me shows that you do at this time, or likely will. Labor improves the hormonal function of you and your child.

I probably sound a bit forceful. It is just a response to finding a woman in your position. I believe you that your community birth environment has got you to this point.
Let me say that I believe in you, in the design of birth within us both, and in your ability to give birth to your little one.

There is a community of birthing women who can become your community, too.

Saturday, December 8, 2007

Doulas too?

One more post here in response to Joyce McFadden's blog From Doulas to Doctors; Women are still dismissed." Here is an extract :

  • A woman says to her male doctor, "Since the surgery I have pain right here." The doctor says, "That's not possible." Almost a year and at least $5,000 worth of medical expenses later, she's proven right. A woman says to her female doula, "There's something wrong with the labor, I need to go to the hospital right now." The doula repeatedly tells her she should just hang in there, it's not time yet, which proves to be a bad error in judgment.

See that middle sentence? That's a problem.

I'm so glad that Penny Simkin teaches in her doula trainings and conference sessions the sage point that a doula must leave her agenda at the door and let the mother lead her birth.

When encouragement turns to persuasion the gift of the doula is crumpled. There is an urge among either the naive new doula or the doula on a crusade to rescue birthing women. I'm not saying it isn't motivated from a reasonable desire to protect her from the kind of care described in the previous post. But the desire backfires.

When we seek to rescue we loose the equanimity of the mother doula relationship. We are no longer equals, no longer peers. The rescue worker doula has disconnected from the mother's choices to meet the doula's (and this sounds bizarre) desire to offer her more choices.
A pure motivation doesn't justify sloppy communication.

Think about it. I think it is the hardest thing about being a doula. The doula sees the spectrum of behavior coming from medical staff. Some excellent, some brutal. That's a fact. But the mother holds in her heart that she will be welcomed appropriately, celebrated for bringing life, as I've said, and cared for compassionately. She expects that. She may not be thinking defensively about avoiding interventions. And even if she was, it is not the doulas role to prevent her from having them, but only to educate her about them before birth, and to be compassionate about her use or non use of interventions during the birth.

If the mother herself chooses not to use a routine intervention the doula can offer a number of ways to support her choice. But the doula has a line that she can't ethically cross. And certainly that line would be access to care!

If Men could have babies?

I've heard it again. "If men had babies...." Joyce McFadden's blog entry "From Doulas to Doctors" explains well the emotional disruption of being ignored in your own birth process. She says, and the brackets are also hers, "[If men gave birth] I think there would be more transparency in the process, and that patients would be treated with a modicum of respect, and as intelligent, functioning human beings with the right to participate in their own care."

Her blog gives an accurate portrayal of what too many women experience in a setting where surgery is becoming, not second nature, but is replacing "first" nature.

The only thing is, is that her conclusion is off. Women doctors are not inherently more respectful of women patients, not OB patients. Each male or female doctor makes the decision for themselves whether to extend themselves beyond their technical performance and reach out to the heart of the patient. In other words, are they living as a healer or a technician?

I was a doula for a woman who picked a prestigious all-female OB group. She told me in her pregnancy how reassuring it was to have women caring for her. Women, who understood what it was to be in her position, pregnant and wanting compassion and celebration for this miracle of bringing life.

Her labor went fast. In fact, so fast that the doctor and I came into the room while the mom was crowning in 2nd stage. So fast, that I began to coach (a term and a style I don't normally use, but it fit at this moment) as I crossed the room to help the mom cope with the feeling of stretching skin around her baby's eager head.

""It's ok, its your baby's head coming." I didn't want to direct the birth, but I also didn't want her to push her baby out hard into the air unattended, because the doctor was still gloving up. So as not to put myself in the place of the baby catcher, I said, "Your doctor is going to tell you how to pant so the baby's head comes out smoothly." I was trying to get that word "pant" in there.

But to my surprise, and the mother's, her doctor wheeled around and shouted, "I'm the doctor here, and I am cutting an episiotomy." I'm sure her far sighted vision was able to see across the room (and around the back of her head) that the crowning baby was stuck or the yielding perineum of her patient was going to burst or something noble motivated this woman doctor.
She swept across the room and deftly grabbed her favored implement and quickly cut the mother open even as the baby was emerging.

I can go on to describe numerous similar descriptions of women who cut without reason, who use the vacuum on actively birth women, who threaten the mothers with the death of their child if they don't submit to induction. And this last by nurse-midwives.

On the other hand, I've been a doula to women who have the nurse-midwife group in town that includes one male midwife. Early in their care, mothers sometimes say, I don't want the male midwife, I want a woman at my birth. Usually at some point in their pregnancy they end up seeing John. A big smile comes over their face. Several have said they almost prefer John to the other midwives they've seen.

You see in each case, we chose to be present with who we are with, or we don't. Its not the gender, its the power a person supposes they have over another person. The illusion of power disconnects you from humanity.

If a doctor or midwife doesn't acknowledge informed consent, or acknowledge the voice of the woman at all, they have no motive to connect with her. Their sentiment may be for the relationships with the nurses. They are chatty because they are exercising their power among nursing staff who have to work in the OR and listen to the doctors. They smile, of course, like paid admiration. The nurses want to get along with their co-workers, including the docs, so its not wrong to establish working relationships. It is wrong to desecrate the sanctity of a mother's birth.

Is this disconnect the price of technology and the cost of high paid technicians? Do we allow them this power because they save lives? Do we sacrifice the quality of life for nearly all new mothers so that we can save the lives of a few? And if so, then why are we losing more babies than countries with less technology? We aren't getting the rewards of our sacrifice.

I rapidly go to the larger problem. If it is seen as gender, it may be because, as a society, and too often as individual women, we have given the male gender the power to disconnect from us. Put a woman in that place of power and we see the same pattern of disconnect.
The pattern is there. We have to transcend the pattern, not the gender. The gender is besides the point.

Friday, December 7, 2007

Might as well accept surgery?

A woman pregnant with breech twins emailed saying her physician recommended signing up for surgery. He predicted that they weren't going to flip head down. Yet, she was less than 32 weeks pregnant!

The direction a twin lies in is determined by the same things that determines a single baby's direction. Plus one more thing, the other twin.

While they are still little, helping the mother with her soft tissue symmetry can help them both be head down. The ideal time to work on this is before or during the 2nd trimester. Yet, twins still have a good chance of turning head down when they are but 32 weeks.

As the pregnancy passes the 30 week mark, some body work and maternal activities will help reduce any possible twist in the lower uterine segment or pelvic misalignment that might prevent head down positions. See the 3 Principles of Spinning Babies. And, while you are there, read the Pregnant with twins article.

When your uterus is symmetrical the babies can more readily turn head down with gravity.

We all might consider that a doctor who is setting a woman up for a cesarean this early in pregnancy will find other ways to arrange a cesarean after the babies turn head down. Predicting a cesarean two months before the babies are due is more of a sign of our litigation society and the profit motive of hospitals than a reflection of a physician's intuition or grasp of the nature of birth.

If, at any point, you agree to a scheduled cesarean, then ask if there is any responsible motive to add prematurity to the surgical risks.

A woman would have to stand her ground to have your surgery at full term, 40 weeks or after labor begins.
The March of Dimes is concerned with "late prematurity" and the increase in infant mortality caused by induction or scheduled cesareans that are unintentionally early
.
This sounds like a strong opinion, but is a summary of the data.
Furthermore, read Dr. Brewer for info on a healthy diet that is wonderful for twin pregnancy.

Changing the Earth by supporting Birth

Mothers bring forth life; medical corporations do not. Birth can be simple, powerful and loving. Fetal positioning, natural birthing and practical help for normal birth.