One woman's path through doula training, childrearing, and a computer science Ph. D. program

Tuesday, December 7, 2010

The nighttime smells like hospitals

Maybe it is because I do not stay out late anymore unless I am attending a birth.  Maybe it is because the floors were freshly cleaned.  But when I was working late in my lab last night at the University, when I left my office to walk down the long, clean hallway to the stairs, when I could hear my shoes squeak gently beneath me with each light, quick step, I could swear it smelled like, and felt like, the hospital.  I did a double-take.

There are two possibilities.  Either it was in my mind, or it was in my hallway.  Probably, a combination of the two.  But it really threw me for a loop.

The only times recently --- in the past year --- that I had been out past 8pm were to attend births.  Both birth centers that I have been to smell like cleaning agents, blue hospital gowns, and hand sanitizer.  With just one exception, each birth I attended was at night, with nobody else around: an empty parking lot, no visitors, and reduced hospital staff.  Inside the hospital, long, clean hallways with wide linoleum separate the main entrance from the nurse's station and from the patient rooms.  In our engineering building, the nurse's station is replaced by a small shared kitchen in which an espresso machine delivers medicine rather than a labor and delivery nurse.  So for me, being out at this hour, walking down similar hallways, with nobody else around, down the echoing staircase, into the empty parking lot, I felt like I was returning home from a birth rather than my own research.

Sunday, December 5, 2010

Epidural birth and doula support

An unfortunate reality is when women in labor choose to have epidural anesthesia administered, they are usually abandoned by their birth partners.  Erroneously, birth partners think: Why stick around?  There is no more pain, and hence, nothing for a support person to do.

This could not be farther from the truth.

What follows is my account of supporting a couple through a normal, vaginal birth, with epidural anesthesia.


I met Lucy at a breastfeeding support meeting through La Leche League International.  I go to these monthly meetings to, well, support my habit, and to offer support to mothers with children younger than mine.  Lucy was one of the two pregnant women that came to learn more about breastfeeding in preparation for their births.  After the session, I approached her; we met that weekend with her husband, Mike, and seemed to get along well.  Lucy and Mike desired a normal birth but with pain relief, hoping to delay it as much as possible, but keeping in mind that Lucy was not interested in experiencing a lot of discomfort.  Over the next weeks, Lucy and I talked by e-mail, and when Mike was out of town, I went with her to her prenatal class at the nearby hospital.

Then, there was an interesting shift in how Lucy and Mike felt about the upcoming birth.  After taking the childbirth class, Lucy said that they really did a 180: they would really like to try natural childbirth, without the use of pain medications and instead using natural comfort measures.  I glanced at Mike.

"And how do you feel about this?" I asked him.

"Well, whatever Lucy wants," Mike shrugged.

I asked Lucy, "What do you think I should do or tell you when, at some point in labor, you happen to request drugs?"

She thought a moment.  "Remind me of the baby," she said.  "Tell me about the cute clothes we have lined up for him.  Tell me about the baby."

"OK, so, distract you.  If you call out for pain medications, I should take it as a sign that you want more support."

"Yes," she said.

Stripped membranes and early labor

On the first day of her 39th week of gestation, Lucy went to her doctor for her regular prenatal check-up.   A week before, we met again at the LLL meeting; the other woman that had been pregnant two months ago was there with her six-week-old infant, but Lucy was still very pregnant.  The topic turned to birth stories, and to how my doctor had stripped my membranes at my 38-week appointment, triggering my labor.  Stripping (sometimes called sweeping) the membranes is done during a vaginal exam, when the doctor inserts one or two fingers into the uterus and lifts the amniotic sac from the cervix.  I was resentful for having my membranes stripped because my doctor neither warned me nor asked my permission to do the procedure.  Nevertheless, the topic of triggering labor was hot on Lucy's mind at this appointment, and she asked her doctor for advice.

"Would you like me to try stripping your membranes while I examine you?" he asked Lucy, washing his hands.

"Will it hurt?" she asked.

"No more than a vaginal exam," he said.  "But there's only about a 50% chance that it will work.  If it does, it will probably trigger labor in one to three days."

Lucy agreed to try it, and, six hours later, at 6pm, called me in labor.

"These contractions are so different than the Braxton-Hicks I was feeling earlier," she explained when I asked what the contractions feel like.  "The best way to describe the difference is that these hurt.  I thought they weren't supposed to hurt until much later."

Knowing that early labor for first-time moms can last several hours, I told her to eat, drink water after every contraction, and rest.  Take a shower, use a heat pack on her back if it is sore.  Over the phone, I described how to toast rice in the oven and place it in a sock.  I told her to call back whenever she wanted me to come.

A mere two hours later, Mike called back.

"We want to go to the hospital," he said.  I could hear Lucy moaning in the background: low, beautiful birth sounds.

"Can you wait until I come meet you at your house?" I said.  "Get Lucy in the shower.  Have her take a bath.  I will put my kid to bed, get my stuff together, and come right over."

The biggest hurdle for all three of us --- Mike, Lucy, and me --- was the long drive ahead.  Not wanting to switch obstetricians after moving, we were affiliated with a hospital 50 minutes away by vigorous driving.  We had talked previously about what it would be like to labor in the car, and, for a while, Mike and Lucy had a plan of renting a hotel room during early labor.  The long, unpleasant car trip to the hospital was the determining factor in Lucy and Mike's haste in getting on the road.  If the contractions were barely manageable now, what would they be like in the car, and what would they be like an hour later?

Twenty minutes had gone by; my son was nursing happily and humming in bed when the phone rang again.  Lucy's bellow was heard in the background when Mike talked.  The contractions were three minutes apart; Mike and Lucy were leaving.

"I'm on my way," I said.  Hanging up the phone, I unceremoniously decoupled myself from my son, who started crying.  "Sorry," I said, "mama has to go to work."  I picked up my bag, grabbed the car key, and was off.

Hospital admittance and the nurse from hell

On the way to the hospital, I had a lot of time to worry.  What if labor was progressing very fast, and I was wrong to be so dismissive of Lucy's early labor?  Judging by the contractions and their intensity, Lucy was likely entering active labor, and I was not there for her.  I was already failing her as a doula, and I was not even there yet!

When I arrived, Lucy had changed into the hospital gown.  She was pacing around her room, stopping for contractions to hug Mike.  Rather than bending forward at the waist during contractions, she bent backwards, closing her eyes, and moaning.  Nurse Gwen was coming in and out, gruffly collecting intake information on the patient.  She did not stop for contractions nor offer any sympathy to Lucy's discomfort.

"What is the due date?" she asked.

"Uhhhhnnnnngggg," Lucy replied softly.  Mike answered the nurse.

Several contractions went by in this way: Nurse Gwen asked a question, Lucy tried to focus, Mike answered.  Finally, Nurse Gwen left for a few minutes.

"How was your ride over?" I asked.

"Terrible," Lucy replied.  "I was screaming the whole way."

"Windows up or down?"

"Down," Lucy replied, and went to the toilet.

When Nurse Gwen came back, she tried to start an IV, but somehow missed the vein.  I watched as she hastily, with trembling fingers, maneuvered the flexible needle under the skin, hoping to accidentally poke it and correct the mistake.  She apologized, removed the needle, and tried again on the opposite arm --- again missing.  She tried for a third time and missed again.  Frustrated, she offered a cervical exam, checking Lucy by having her lie down on the bed and lowering the back support all the way.  Luckily, the nurse was fast, because Lucy was in greatest discomfort in this position.  The reading came back: 3cm.  Early labor, with a long time to go.

"How many more contractions are left before the baby is born?" Lucy asked Nurse Gwen.

"About 314," I said, grinning.  "I counted."

Nurse Gwen shot me an annoyed glance, correcting me.  "It is impossible to know.  It is different for every woman, and every birth.  Just get through them one at a time."

The next time Lucy went to the toilet, Mike asked: "So, what is wrong with getting a little help?" --- meaning drugs.

"Nothing," I replied, "but it is not on your birth plan.  We agreed to try to labor naturally."

A few contractions passed well: Lucy's hips swayed from side to side as she hung on to Mike's shoulders.  She moaned.  She made all the right rhythmic movements and all the right low tones.  But she complained of pain.  My positive comments about how great she is doing and how wonderful she sounded and how her swaying is perfect --- they were not enough.

Nurse Gwen strutted back into the room and announced, during a contraction: "We need to get 20 minutes of tape on the monitor."  She had Lucy get back in the bed and applied the external fetal monitor and the contraction monitor paddles to her stomach.  Then she finally started an IV, in the vein between the thumb and forearm of Lucy's dominant hand, preventing any range of motion with it.

"Do you have wireless monitors, so we can keep walking around?" I asked.  The answer: No.

In bed, there was one contraction that Lucy handled particularly well.  Her head bobbed from side to side as she breathed.  But once she was able (and instructed) to get up again, to put on shoes and a robe and walk, she faltered.

"I need an epidural," she said during a contraction, and repeated after it subsided.  Over the next two contractions we argued about it --- rather, she insisted, providing compelling arguments, talked about suffering, repeated the pros and cons, and I tried to talk her into trying other things.  Let's get in the shower.  Let's go for a walk.  How about leaning against the wall.  I looked at Mike; he looked forlorn.

Then, I said:  "I am going to support you no matter what you decide.  I am here for you."

"Do you want to try the small help first?" asked Mike, meaning Fentanyl, the intravenous narcotic.

"No," Lucy replied, "the big help."

Thus, the decision was made.  The anaesthesiologist was summoned from his home 30 minutes away.

Choosing an epidural

The hardest part for a woman that has chosen to receive anesthetics in labor, but has not received them yet, is coping with the contractions that lie between her and her medicine.  During contractions, we counted up to ten, then back down.  Mike rubbed Lucy's shoulders.  We watched the clock, noting how long it had been since her request (and erring on too short of an interval).  We moaned.

It was midnight.  The anaesthesiologist was a tall man with small, funny, round glasses.  "I am very fast," he said when Lucy asked him to be swift.  Skillfully and quickly, he placed the epidural, and Lucy's sensation of her contractions slowly subsided.  First, they lessened in duration, then she felt only the peaks, and, finally, she felt nothing.

Intense joy swept over Lucy.  She chatted gaily; we watched the strip reading out contraction strengths.  We talked about the baby, about how wonderful it is to be able to focus again on what this is all about: having a baby, on the momentous, happy occasion.

"I had forgotten about all of that," Lucy said.  "It is so nice to be able to really enjoy having this baby again.  I was so unhappy."

After a while, I suggested we all sleep.  The annoying, gruff Gwen suggested the same, turning on the lights as she came in for a set of strip readings and another exam.  When she left, we dimmed the lights and tried to rest: Lucy in bed, Mike on the cot, and me in the armchair.

Breaking the waters and waiting to push

What does a woman do when she is in labor but feels very little of it?  What does she do while she waits for her chance to push?  Knowing it was hours away, and knowing we should all conserve our strength, we tried to rest.  But for a woman in labor, this period of waiting is intensely surreal and frightening.  She wants to know that everything is progressing normally, that her baby is all right, that she is still in labor, and she worries, in a sort of performance anxiety, about her ability to push effectively (women are said to be able to push more effectively if they can feel the pushing contractions).  She worries about her labor pains returning, as the epidural feels too good to be true.  She worries that the drugs from the epidural affect her baby and her baby's ability to breastfeed.

Our goal was to wait for 10cm dilation and +2 station, indicating that the baby had dropped low enough that our pushing efforts would not be wasted.  At this point, Nurse Gwen was, to our pleasant surprise, was replaced by a much nicer, pleasant, and accommodating nurse named Maggie.  Maggie explained that the ballpark is one centimeter dilation per hour.  We calculated: if the epidural was started at 3cm at midnight, we should expect to be complete at 7am.

At 8cm, Maggie suggested that the doctor be summoned for AROM, or artificial rupture of the membranes or amniotomy.  These are equivalent names for breaking the bag of waters, a procedure sometimes used to speed labor along if the bag does not break on its own.  Given the good progress to this point, the 24-hour time limit usually imposed on birth after the bag has ruptured was not an issue.  Moreover, Lucy's position (in bed) was not likely to aid the bag in rupturing on its own.  We agreed.  The obstetrician made his first appearance, barely looking around the room.  I greeted him gaily, introducing myself as doula.  Ignoring me while giving me a sidelong glance, he announced his intention for amniotomy, and, before Lucy could ask if it would hurt, the procedure was done (it did not hurt).  The fluid was clear.  The obstetrician announced 7cm, and Maggie explained that it is normal for the cervix to "snap back" after the dilating pressure from the bulging bag was removed.  She assured Lucy and Mike that labor would progress normally.

Although I will skip ahead a bit, I will mention two other interventions that either happened independently or followed AROM.  The baby's heart rate would sometimes decelerate after some contractions, causing a bit of alarm for Nurse Maggie.  First, Lucy received oxygen nearly continuously for most of her labor, and every 20 minutes Nurse Maggie would come and move Lucy: if she was on her left, she would be flipped to her right, and vice-versa.  Second, at about 9cm, the obstetrician inserted an intrauterine pressure catheter (used to measure the strength of contractions, but in our case, this was largely ignored) and ran fluid into the uterus.  This procedure, called amnioinfusion, is, in the grand scheme of things, minimally invasive.  A catheter is placed next to the baby's head, and sterile saline solution is delivered into the uterus to replace the amniotic fluid which is, at this point, gone.


Three things clued us in on the upcoming pushing phase of labor.  First, Lucy began feeling pressure on the top of her uterus rather than all over, or even on the base of the uterus, as she did before the epidural. In early and active labor, a woman's cervix dilates.  Women can feel this low in the abdomen.  As active labor moves into transition and pushing, the contractions change into powerful presses from the top of the uterus, just under the breasts.  Second, contractions were close together --- two minutes apart --- and lasting over a minute, as measured on the strip.  Third, Nurse Alyssa (who replaced Nurse Maggie when her shift ended) performed gentle vaginal exams revealed bloody show and that she was complete and the baby at the +1 station, but the cervix had a "lip" which slowly dissipated over the course of about two hours.

What can I say about medicated pushing?  It happens in the traditional supine position, legs elevated and held back by two people.  Lucy felt the contractions; she pushed very effectively.  Her baby was born in just one hour: first, a squished, chubby, cone-shaped, purple head, and then a comparatively skinny white body.  Later, Lucy confided that she thought we were trying to be falsely encouraging when we said things like "I can see the baby's head" and "You are really making some progress," because it was impossible for her to feel the progress she was making.  She was a magnificent pusher.  Lucy: Pusher of Babies.

The baby was placed on her chest directly after birth.  Mike cut the cord; Lucy crooned at their new baby; we all cried as I took photos with Mike's camera.  The obstetrician sewed up Lucy's second-degree tear and helped Lucy deliver her placenta.

I stayed for about two more hours, trying to help the baby breastfeed.  He would put the nipple in his mouth, but would not suck.  I assured Mike and Lucy that it was just a matter of time; the baby was tired and sleepy.  "When the nipple slips out of his mouth, he cries.  This is a good sign," I said, "it means he is interested.  It will come in time."  And it did.  By evening, the baby nursed.


I was pleasantly surprised that the unfortunate cascade of interventions women fear yet anticipate after opting for an epidural did not happen for Lucy and Mike.  There was no need for pitocin; there was no need for C-section; there was no need for episiotomy nor instrumental delivery.

Natural birth is undisputedly the safest form of birth, both in terms of mother's postpartum health and the baby's health, but it is not the only kind of birth that is safe.  There is a definite need for medicated birth in our society.  It goes without saying that a healthy baby is the most desirable outcome of a birth, but the mother's experience with the birth is arguably just as important to the mother as the baby's health.  Her birth experience is her memory of this most momentous occasion, and should be regarded with as much care as such an occasion warrants --- that is to say, it is very important.  At no point should the mother be made to feel that she is suffering.  And, once requesting and accepting a medicated birth, at no point should she feel guilty for her decision: she is doing her absolute best, and should be applauded.  The mother should be able to look back on her birth and be proud of herself, to feel empowered.

It is OK to choose an epidural. Lucy did, and she had an amazing birth.

Saturday, November 13, 2010

Two reasons Facebook is killing information retrieval and collaboration

There are two problems plaguing Facebook and having a grossly detrimental effect on information retrieval and collaboration.  If you see Facebook as more than a lolspeak haven, and use it to communicate information to your friends, like I do, you may be seeing the same problems.

Facebook is killing information retrieval

The first problem is that, like many of my online friends, the majority of my interaction with Facebook is through status updates and sharing links to interesting stories.  Some of these links are particularly compelling or memorable for me: months later, I wish to retrieve these links, and revisit the site.  Perhaps there was an interesting article that was germain to my current research, or that helped articulate a point.

Unfortunately, link retrieval on Facebook goes like this:
  1. Click on my name to go to my profile and wall.
  2. Search the page in my web browser for the text I think I put in the link text.
  3. Finding nothing, scroll to the bottom and choose "Older posts."
  4. Wait.
  5. Repeat steps 2--4 until either I find the link, or I get bored.
This problem is compounded if the information I wish to retrieve is embedded as a reply to someone else's status update or link.  These events are archived on Facebook, and displayed back to me, as "Dynamic Doula commented on So-and-So's status" or "wrote on So-and-So's wall."  If I am unsure where the embedded information is, on whose wall I wrote, or on whose link I commented, I have to traverse all of these links.  Click, read, realize it is not the correct one, go back, and start again on step 2, because all of the "Older posts" have been re-minimized and only the newest posts are displayed.

Information retrieval on Facebook is cumbersome.  I wish there were a way I could easily and quickly search all of the things I have ever written, both on my wall and on others' walls, and in discussion groups within individual applications.  How many times have I linked, for example, a story about a birth?  Where are all of my links to blog posts?  Where is that amazing conversation we had about children in academia?  These things are nearly impossible to find, as they have disappeared into the informational Facebook abyss.

Facebook is killing collaboration

The second problem with Facebook (or at least, the second problem that I address here) is a direct fallout from the information retrieval problem.  Say I share a link to a blog post, such as this one.  Those in my friends list are shown this link, and can "like" it, comment on it, or share it with their friends. Conversations, including the "like" action and actual comments, about the post happen directly below my link, as replies.  However, readers of my blog that are not friends with me on Facebook are thus prevented from contributing to the conversation.  Moreover, if a friend shares my story on her feed, there is a possibility of further conversation on that node, totally disconnected from the conversation on my node.  To keep track, I should either "like" or comment below any shared articles to be notified of replies.  There is no way to consolidate the conversations.

The real problem is that Facebook is a closed system.  That is, only members of Facebook can contribute to its content.  I am generalizing here, and not even touching ads and the recent privacy concerns and the way that, magically, other sites suddenly know a lot about my friends and their interests.  As it's a closed system, it is difficult if not impossible to selectively make public certain content without compromising privacy.  In particular, I cannot tell the world about what my Facebook friends think about my work, because their comments are published on Facebook.  And their friends cannot tell me what they think of my work, because they lack the permissions to post on my wall.  Oops!  It is a privacy catch-22.

What Facebook should do

The solution to these two problems can take many different turns.

First, Facebook should provide a search function and an easier way to access one's own content.  Period.

Second, Facebook and Blogger (or other blogging tools) can add a way to publish comments from Facebook to Blogger and vice-versa.  That is, if someone comments on a link to this article on Facebook, there should be an option for anonymization (if necessary) and publishing to Blogger.  That way these comments can reach more of the general reader population.

What I should do

I do not really know how to proceed.  I would love to be able to post here on my blog some of the lovely feedback and serious discussions I have had over Facebook, but one, I would need to get permission or properly anonymize each comment; two, I would need to enter each one by hand as a comment (which would be both tedious and, well, lame); and three, I would need to be able to find them, which brings me back to the first problem above.

Instead, I will solicit advice here, and silently stew in my progressively-escalating annoyance with Facebook's downright unusable information retrieval system and lack of cross-system collaboration support.

Friday, November 12, 2010

C-Section and doula support

I had the privilege recently of attending a scheduled Caesarean section, or c-section, birth as a support person.  Notice I did not say that I was "the" support person.  That was the mother's partner's job.  My job was to support the couple before, during, and immediately after major abdominal surgery.  Here is my account of the events that transpired surrounding this birth.

Alice and Bob (not real names, of course) contacted me around 21 weeks gestation (out of the average gestation of 40 weeks).  We met and hit it off, and started preparing together for Clara's birth.  Alice and Bob attended six weeks of childbirth class, during which they practiced breathing and relaxation, studied the signs of labor, and watched videos of babies erupting from their mothers' vaginas.  We met several times throughout the progress of the pregnancy, and wrote back and forth a few times a week.  A birth "wish list" formed --- a wish list like so many other wish lists: minimal interventions, stay home as long as possible, hold the baby immediately after birth, breastfeed within the first hour.

But as the due date approached, the pregnancy landscape changed.  Alice's blood pressure rose, then dropped, then rose.  Clara was kicking, then still, then kicking.  Alice developed an irregular heartbeat, but only sometimes.  Clara stopped growing for a while.

"[My doctor] is talking c-section at 38 weeks," Alice wrote.  "I'm not sure how I feel about it.  Is there support for a doula to give if there is a c-section scenario?"

"Absolutely," I replied, and explained what a doula can do: stay with mom while dad goes with the baby; keep mom company, explain what is happening, and take photographs of the event for reconstruction later.

In a couple more appointments and emergency room visits, the date solidified.  Alice's obstetrician, arguably the best in the county, gave a very compelling argument that C-section was the only way their baby could be born safely.  We all agreed.  It is a bit surreal to know exactly when a baby would be born.  In normal birth, the expectation of when the birth would occur is nearly random, but here, we had a date.  Two days before the birth date, I dropped off to Alice and Bob's house the Cesarean Section book that I got at the library, as well as some other birth books that happened to have a brief, inadequate section on C-sections.

On the birthday, I arrived at the hospital just after the parents-to-be had checked in, changed, and settled in to their room at the birth center.  This birth center is not like other birth centers: it is a fully-formed hospital, with operating rooms and anaesthesiologists along with birth rooms with large tubs and showers.  The center's C-section rate is 14% at the time of this writing [1]: well-below the state average of around 26.8% [2], and an applaudable rate, given that it is a for-profit hospital.  Women giving birth at for-profit hospitals are nearly 17% more likely to end up with a C-section [3].

Alice was in bed in her hospital gown.  A nurse was trying to start an IV (part of the prep work for surgery).  Bob was sitting on the ledge under the window, and their friend Dora sat in the rocking chair.  The surgery was scheduled for two hours' hence, so we had quite a bit of time to kill.  The nurse kept trying to find a vein in Alice's dehydrated arms: Alice was forbidden from eating or drinking anything since the night before, which, as any pregnant lady knows, is a tall order.  She missed three times before the IV started to flow, on her fourth attempt.  Alice took this in stride and apologized for her shriveled veins.  We all laughed.

Perhaps one of the hardest jobs for a doula is to find a way to occupy down-time prior to something scary.  Luckily, Alice and Bob and Dora and I shared a sense of humor.  We made jokes.  We talked a mile a minute --- about boyfriends and college and kids.  We took photos.  We wondered, picking apart our own birth experiences (Dora had had a child by C-section).  Mostly, we waited.

My biggest concern in the wait to surgery was that the anaesthesiologist would not permit me to attend the C-section.  The final decision does not fall on the obstetrician, who had OK'ed my presence as a support person, but the anaesthesiologist, who stands at the patient's head, and who would have to share the space with both the mother's support people: Bob and me.

When the nurse finally came and produced two gowns, hair nets, shoe covers, and masks, I was thrilled. Bob and I donned our light blue attire, and gleefully photographed each other.  All three of us (Alice, Bob, and I) were escorted from the room, and Alice exchanged nervous, giggling good-byes with Dora. Alice was taken to a room down the hall, separated from the hallway by two sets of double doors, and shown inside.  Bob and I were asked to wait outside, by which we assumed it was meant inside one of the sets of doors.  Through the gridded window, we took photos of the operating room and of Alice and of the doctors and nurses bustling about.  Quickly, we were asked to leave and wait outside.

I will take this opportunity to say something about my behavior.  In this setting, with this particular couple, it really worked to be upbeat and jocular, to keep the atmosphere light and bright, and to play up anything even remotely funny.  Humor is one of the best coping mechanisms we have in the face of stress.  I know the significance and the gravity of major abdominal surgery, and I know how intensely painful it can be on the outside of the operating room doors.  Waiting is the most difficult thing we can do when someone we adore is under the knife and we stand around, helplessly waiting for news of well-being.  This is especially true when it is a mother and her baby.

When I was a teenager, my mother was in the hospital for a surgery.  My grandmother, my mother's mother, and I waited in the designated area.  The surgery was taking a very long time --- longer than we anticipated --- and we were both on edge.  On a whim, I started making up a story about what was taking so long: the doctor must have dropped a contact lens into the surgical site and was looking for it.  I used colorful adjectives, and acted out the story, and soon we were both trying hard to contain our nervous, wracked giggles.  I looked over and there was another woman in the waiting area watching us and laughing, tears glistening in her eyes.  She said, "I can't understand a word you are saying, but it has to be hilarious!"  If nothing else, it made the time pass faster and easier.

After a few minutes, or, closer to half an hour, of standing in the hall, watching the janitor vacuuming, and guessing the upcoming time of birth (Dora was the closest, off by just one minute), we were asked to come back in.  The operation had already begun.  In this time, Alice's spinal and epidural were administered (this birth center uses a combined spinal and epidural anesthesia), her belly scrubbed and covered with clear film, and the first incisions were made.

Bob hurried to Alice's left hand, which was strapped to the table, away from her body.  I stood by Alice's head.  Occasionally, we peeked over the curtain dividing Alice's head from her abdomen and described what was happening.  The anaesthesiologist, a small, thin, Asian man whom I will call Dr. Kim, picked up on our light tone and joined in on the conversation.  Soon, the baby was ready to be born.  Alice's obstetrician warned Alice that she may feel something, and began, lowering the partition slightly so that Bob could have a better view of the upcoming birth.

It is difficult to prepare for this moment.  Books may say that a mother may have some tugging sensations, but it is impossible to express how foreign these sensations are.  Especially after several hours of relaxation, reclined in a hospital bed; especially after some time with a spinal, blocking all sensation below the lungs; especially never to have felt such a force coming from inside the body --- imagine the strongest baby in the world twisting and turning in utero --- to suddenly, quite unexpectedly, feel the doctor pull, push, yank, maneuver, and otherwise manipulate large portions of your torso in the effort of removing a fetus from a uterus --- this is alarming, and, even though the pain nerve fibers are immersed in anaesthetics, on some level, painful.  Alice's obstetrician, aside from being known for catching life-threatening problems in the mother and saving her from statistically-significant chance of harm, thus defying all odds, is also known for making perhaps the smallest incision --- hence the overzealous pulling and pushing of the baby to deliver her through this small opening.

I was glad Alice and Bob prepared for natural childbirth and practiced breathing and relaxation, because if ever, Alice needed it now.  Between breaths together, I explained what was happening: The head is born.  Now one shoulder.  Both shoulders are born.  Your baby is born.

Faster than I could blink, the cord was cut and Clara was rushed to the baby warmer to our right, where two nurses rubbed Clara vigorously with warm blankets.  Immediately as Clara sped away with the nurses, Alice's head snapped to the right and stared in her direction.  Bob went to the baby warmer.  There was no sound.

"Is she OK?"

No reply.  Seamlessly, I took Bob's place of holding Alice's hand.

"Why isn't she crying?"

No reply, only vigorous rubbing.  The doctor and his nurse were working quickly on something on Alice's covered half; the two nurses with Clara were joined by a pediatrician.  I looked at Dr. Kim; he looked unfazed.  I took my cue from him.

"Everything is fine," I said, "it just takes some time."

Indeed, just a few very long seconds later, during which it seemed nobody was breathing, Clara uttered her first cries.  My eyes misted.  "That's your baby," I said, through tears, and squeezed Alice's hand.

The tugging on Alice's stomach continued.  I glanced over the partition and told Alice, "You are delivering your placenta."

As her uterus emptied, Alice's body was overcome with hormones and began shaking all over.  I explained that this is natural, and it happens to most women, regardless of mode of birth.  Alice felt nauseous (another common side-effect), and Dr. Kim administered an anti-nausea medicine into Alice's IV.  I continued piecing together what was happening: Now, the uterus is outside of your body and is being massaged.  Would you like a photo?  Now, the baby is being weighed and swaddled.  Now, the nurses are counting rags in preparation for sewing up the uterus in two layers.  Now, Bob is holding Clara.  Can you see?  Between bouts of seriousness, we continued joking at every possible moment.  The only serious moment --- the moment of life --- had passed.  The feeling again became like that of a joyful party (fitting, as we were celebrating a birthday).

In the subsequent minutes, we learned that the baby's cord had been around her neck; more importantly, there was a knot in the cord.  The obstetrician suggested I photograph the cord, and said, "You see this knot?  If she'd tried to have the baby vaginally, a couple of pushes and ugghh," he grunted, "dead baby."  Clearly pleased with himself at his diagnosis and skillful operation, he returned to his work.

The baby was ready to be presented her mother.  Bob brought Clara over to the operating table, holding her at arm's length like a freshly-baked bread.

"Not too close," Alice warned.  "Start slow."

He brought Clara level with Alice's elbow, and we all burst into sobs.  There is nothing more touching than a mother seeing her child for the first time.  Now he held Clara's face against Alice's.  Alice whispered to her baby.  I took photos, but everything looked blurry to me.

It takes about 15 minutes to extract a baby, if the doctor is being careful and taking his (or her) time.  But it takes at least 45 minutes to sew everything up afterwards.

After the surgery, when Alice was being wheeled out on her bed, talking at a thousand words a second, and continuing to crack jokes, Dr. Kim joked, "You are probably the most talkative patient I have ever seen."  We all laughed.

Our triumphant procession marched back to Alice's recovery room, where Dora was waiting nervously (she did not know that we were in high spirits and continued our joyful banter throughout the surgery).  Bob placed the baby in her mother's arms, and the cooing began from all three women.

When I showed Dora the photos I had taken, her eyes misted just as mine had.

"I had no idea what happened during my baby's birth," she explained.  "I don't remember anything, and there were no photos.  I would have loved to have some record of his birth."

I stayed for another couple hours as we all helped Alice nurse Clara.  Clara latched on, nursed, and slept.  Alice's milk came in three days later in full force.

Upon reflection, I was pleasantly surprised by the environment in the operating room.  I had expected a sterile environment, both physically and emotionally, but found that the family-friendly birth center was prepared to make the surgical birth both memorable and meaningful for the new parents.  Aside from the prep period, which happened behind closed doors, the father was never separated from the baby; the doula was never separated from the mother.  Care was taken to include the parents in the cleaning routine for the new baby, and provide photo opportunities wherever possible.  The nurses were friendly while being professional.  Postpartum, the nurses were sensitive to the mother's concerns even before she knew they were concerns.  I was --- I am --- proud to have been allowed to participate in such a meaningful way in this parents' birth experience.


[1] CalHospitalCompare. Accessed 11/12/2010.
[2] March of Dimes (2010). Health Statistics: C-Section Births By State. Accessed 11/12/2010.
[3] Johnson, N (2010). Rate of Cesareans Higher in For-Profit Hospitals. The California Report, September 13, 2010.  Accessed 11/12/2010.

Tuesday, November 9, 2010

Book report: The Woman in the Body

Martin, Emily (2001).  The Woman in the Body: A Cultural Analysis of Reproduction.  Beacon Press, 1987, revised 2001.

My score

My review
The Woman in the Body was recommended to me by one of my committee members.  Emily Martin attempts to find truth with a capital T in how women perceive themselves and their life changes, and how pervasive medical explanations are in our society.  She investigates women's experiences with menstruation, childbirth, and menopause (not reviewed here), starting with the medical model and working through interviews with women of different ages and socioeconomic classes.  As this was the first real anthropological text I have ever read, and as I have never really discussed any of these issues (other than childbirth) with other women, I was fascinated, cover to cover.  The book and its accounts describe a culture similar to my own, with women's experiences that, when averaged, are like mine.  How weird is that?

Расцвела сирень, акация...
В мире нет счастливее меня!
У меня сегодня менструация:
Значит, не беременная я!

(Loose translation: Lilacs and acacias are in bloom / There is none in the world happier than me / Today I have menstruation / Meaning I am not pregnant!)

First, Martin attacks menstruation.  The medical texts describe the monthly flow in overtly negative medical terms, which Martin dubs the failed production model: it is when the egg fails to be fertilized; the tissue dies; the outer uterine layer is shed and expelled.  But many women come to anticipate menstruation gladly as a sign both of fertility and of the lack of a pregnancy.  Interviewing women on their own feelings, she finds two different mental models.  Unsurprisingly, given sex education in school and the bombardment with the all-too-familiar medical model in popular media, middle-class women recite the failed production model as their understanding of menstruation.  But working-class women instead explain the logistical implications, saying that menstruation is when your body changes, that it lasts this many days and requires these modifications in routine and these tools to help you deal with it.  Working-class women were unable to regurgitate the failed production model entirely.

Next, Martin attacks PMS, or premenstrual syndrome, the term associated with the days just before a woman's period during which she may act out, be angry, be clumsy, and be moody.  Women report feeling more sensitive and unhappy with their lives, which makes them lash out at their children and spouses, the latter of which complain of an imperfect wife but brush it off as PMS.  Martin examines the cause of this anger and contrasts American standards (basically, that we all work like robots without regard to our natural ebbs and flows of creativity and productivity) with certain indigenous African cultures, in which menstruating women are considered "unclean" and are given a week off from their usual duties.  In this week, women enter a menstruation hut with other menstruating women, and they relax in making a slow-cooking meal for each other and focus on --- I don't know, I guess becoming cleaner people.  Of course, the menstruation hut is an impossibility in our society given our norms, but the idea is poignant: shedding endometrial tissue is taxing on the body, it affects the mind, and we need a break --- especially in a world that fails to value the work women do in the home.

The failed production model carries over from menstruation to childbirth (and these sentiments are echoed in Pushed (see my review).  Birth is the expelling of a perfect fetus from an imperfect incubator (i.e., the mother).  The mother is producing the fetus, and medicine focuses on this production  There is a timeline for what is considered "normal" (and, for statistical purposes, "normal" is fairly well defined) and any birth deviating from around normal is augmented.  From the moment a pregnant woman in labor enters the hospital, the clock is ticking, and the production of the fetus must happen in the appropriate time.  Martin points out Barbara Rothman's research showing that the time women labor in a hospital has been decreasing linearly since the 1940s [1].  The increasing prevalence of fetal monitors, both internal and external, wireless and wired, transmitting information to the nurses' station, means that medical personnel no longer need to attend to the woman in labor, but to the machine that monitors her.  The woman is becoming an annoying afterthought in the process of expelling the fetus.  Meanwhile, the leading obstetrical text, Williams Obstetrics, fails to mention the mother in the paragraphs about labor and childbirth altogether until the small section on "intra-abdominal pressure," and instead encourages doctors to ally with the fetus, small and innocent, rather than the mother, capable of introducing great harms to the fetus due to the pathological condition which is natural labor.  It is no wonder women in America are striking against the hospital, striking against institutionalized medicine, to take back birth and take back their rights to their bodies!

Then there is the matter of interventions, and especially C-sections.  It is no mystery that our national c-section rate is around 33%.  Is there a difference when you control for race and class?  Of course there is.  Martin poses two theories.
  1. Higher C-section rates for middle-class white women because these women can pay for the privilege of the commodity which is higher health standards.
  2. Higher C-section rates for working-class black women because these women are used as "guinea pigs" in medicine; where new procedures are tested, refined, and perfected.
Martin found both theories supported.  Middle-class white women received C-sections for real medical emergencies, such as prolapsed cord, bleeding, and high blood pressure.  Meanwhile, black working-class women received C-sections for the catch-all phrase "dystocia," which includes and is derived directly from running up against a time limit in labor.  On top of this, black working-class women are mistreated by the hospital staff, being denied pain medication, comfort techniques, and presence of their loved ones.  Martin summarizes how these two groups of women can and, those that feel they must, must resist the hospital environment, to strike and protect their bodies and their rights, in their own ways: 
For a white middle-class woman, the salient issue may be to stall going to the hospital so the clock cannot be started or to organize and demand that all hospitals in the region install birthing rooms; for a white working-class woman, stalling may be an issue, but behind it lurks the larger issue of finding a way to pay for prenatal, obstetrical, or infant care; for a black working-class woman, the issues of stalling and paying may be crucial, but even if she contends with them, she still may have to find a way to avoid downright mistreatment or to manage to have matters explained to her at all.

What is my interpretation of the result of this critical look at women's perception of their own menstruation and childbirth?  Women's experiences with, understanding of, and ways of communicating the details of menstruation and childbirth varies by socioeconomic class and race.  As women progress up the socioeconomic ladder, they become unquestioningly accepting of the medical models from textbooks, by which doctors abide.  As they accept, they are indoctrinated into the system and become part of it, even despite significant research showing the system to be flawed.  There is a silent war between working class and middle-class women: between women that fight the flawed system and are fought by it, and women that have become part of the system, contributing to its flaws.


[1] Barbara Katz Rothman (1983).  Midwives in Transition: The Structure of a Clinical Revolution.  Social Problems, Vol. 30, No. 3, Thematic Issue: Technique and the Conduct of Life (Feb., 1983), pp. 262-271.  University of California Press on behalf of the Society for the Study of Social Problems.
Stable URL:

Wednesday, November 3, 2010

Teaching Childbirth: Top 5 Tools of the Trade

How did people --- doctors, midwives --- learn about childbirth in the past, and how is it done currently? Of course, illustrations depicting what was assumed and known about the female reproductive system have been around for centuries.  My interest is in three-dimensional models.  I will outline a few in the post below.

#5: The antique dolls

These 19th-century dolls were used to teach midwives about the mechanics of childbirth [1].  They were typically made from leather, catgut, and porcelain.  These dolls have limited stretch, mobility, and, frankly, realism, although the attention to detail is present (check out the stretch marks).  The baby is unable to pass through the vaginal canal in these models; instead, a panel on the stomach opens and the baby is lifted out.

There are other dolls, made out of other materials.  Most interestingly is the crochet doll shown below.  Benefits of crochet is that it is stretchy; on the other hand, it is hardly realistic (unless you add copious amounts of pubic hair, as shown).

#4: The Made-in-China childbirth skills training model

Four models in one package are now available for purchase by the general public, so if you ever wanted your own special vagina, this is your chance [3].  This package includes a cervical check model, a childbirth model with fetus, and a perineum cutting simulation.  Wait, what was that?  Oh, yes, an episiotomy model.  Known as "the unkindest cut," episiotomy is a surgical incision in the perineum.  The idea is that such a cut will help the baby be born faster, will prevent tearing, and will be easier to sew up.  Although the baby usually does flop out after the perineal opening is widened, the incision typically tears further, creating both a cut and a tear.  And it has been shown that a clean cut is just as easy to sew up and is just as quick to heal as a natural tear.  Episiotomy is a topic of great debate (and great ridicule) in the West, including the US and most European countries.  But in China, the episiotomy rate ranges between 65% to 93% with a mean of 82% in 2001.  By comparison, the US episiotomy rate was found to be around 33%; the UK rate, the lowest in any European country, was 13%.

#3: The $50,000 pelvis named SIMone

SIMone is probably the most comprehensive pelvis money can buy.  You can practice birthing scenarios at your heart's delight with this amazing computerized model [5].  SIMone's makers suggest that this pelvis also imitates sounds of maternal distress.  I am not quite sure where the speakers are; to be honest, if a pelvis started moaning and crying, I may moan and cry too.

#2: The UK model pelvis and associated childbirth training

This model pelvis and newborn is used to teach obstetricians and any doctor that works around newborns.  The doctors train in delivering the baby in different complicated situations (e.g., shoulder dystocia), and are required to complete this training annually [2].  The doctors may benefit from this training (at least temporarily) because they practice real techniques in real time with a real audience, which simulates the intensely stressful situation that the doctors might encounter with a real woman.

This is actually pretty cool, and I am glad to see some rigorous training being done with these models.

#1: The Japanese Robotic Vagina

Oh, the Japanese.  They come up with amazing things, like the boyfriend arm pillow for women, the woman's lap pillow for men, and Le Trung's perfect woman named Aiko.  Now, we cut to the chase, eliminating the middle-man: the robotic vagina.

I must say that I searched far and wide for a reputable source for the robotic vagina, but came up with pages of URLs of the form "Japanese Robotic Vagina: Now Making Childbirth Even More Horrifying."  A still picture makes little sense; you have to see the video.  With the sound off.  Those servo motors are ridiculously loud.


With the exception of the early birth dolls, which contained a full body and an expressionless face, the models of modern-day have, at best, only a torso, a highly realistic and anatomically correct vagina, and sometimes stumps for legs.  Why is this unsettling?  Well.  Pregnant women, and women in labor, frequently complain about doctors not really seeing them as people.  Doctors come in, look at the belly, look at the chart, bark some orders, and leave.  "He didn't even look at my face," women complain, without loss of generality to gender of the physician.  This fragmentation between woman and her body, between woman and her genitalia, transcends the physician boundary and permeates women.  Women describe their bodies as outside themselves.  "The uterus contracts," they say, de-emphasizing that the uterus is part of themselves [6].

Using this faceless, limbless, body-less model of a vagina, and training doctors to look only there, with total disregard to the rest of the woman as a person, perpetuates the notion that women are invisible: only the reproductive tract is important, and only the product of the production model of childbirth (i.e., the baby) is important.  But to many women in Western society, the experience of birth is just as important as the outcome (the healthy baby).  If we, women, are treated by what amounts to medical superiors as a limbless abdomen, we are made to feel insignificant.

Of course, building a full-body model, complete with a face capable of emotion, is prohibitive.  But perhaps incorporating sensitivity to the concerns and emotions of women in labor into the training, when using these models, will make a step in the right direction.  Perhaps it will help.


There are many other childbirth models available for purchase both by hospitals and by individuals.  This list is not intended to be exhaustive.


[1] Wright, A. (2009) Birthing Dolls. ProfoundlySuperficial (blog), May 24, 2009. Accessed 11/3/2010
[2] Bavley, A. (2008) KU Hospital First in Nation to Use Course for Childbirth Emergencies. The Kansas City Star via NursingLink, August 14, 2008. Accessed 11/3/2010
[3] Childbirth Skills Training Model. Accessed 11/3/2010.
[4] Graham, I. D., Carroli, G., Davies, C. and Medves, J. M. (2005), Episiotomy Rates Around the World: An Update. Birth, 32: 219–223. doi: 10.1111/j.0730-7659.2005.00373.x
[5] Gynecological Models, Obstetric Models, and Childbirth Models. Accessed 11/3/2010
[6] Martin, E. (1987) The Woman in the Body. Beacon Press, Boston.

Monday, November 1, 2010

Only women would find this interesting.

A little bird told me this story about perceptions of my research in helping people learn about childbirth through video games.  This story has been anonymized as much as possible.

I was speaking with my advisor after a group meeting with another professor on my future advancement and dissertation committee.

"I am going to present at the research event on campus this morning," my advisor began.  I nodded attentively.  "I showed my slides to the dean."  She continued:

"'These are interesting projects,' the dean said. 'Except this one, about childbirth. Perhaps you should leave it out.'

"'I'm not going to leave this out,' I told him, 'it's my student's work!'"

"'Well, maybe if you have time, you could mention it at the end.  It's just not very compelling.'

"I told him, 'No! I'm going to present my student's work.'

"'Maybe,' he said, 'if there are women in the audience, they might find it interesting.'"

We both had a good laugh.  I stooped to pick up my jaw from the floor.

And even now, I just do not know what to say.  This kind of gendered mindset is the reason we still have sexism and the reason fantastic essay-books such as Beyond Barbie and Mortal Kombat exist, to raise awareness and teach us that gender is not necessarily a good predictor of the success of certain games.

Anyway, I am not sure what I expect next.  At the poster session the same day, I stood in front of my poster and received positive feedback from nearly everybody that passed by.  I saw the dean amidst the scholars, usually with his back to me.  He had his back to the whole games group and both of us human-computer-interaction (HCI) students.  He never came over to see what we were about.

What bothers me most is that the dean fails to realize that what he said to my advisor was not only controversial, it was sexist, bigoted, and incorrect.  When I tested my childbirth video game, most of the participants were male, and overwhelmingly, the game was rated as pretty damn fun.  Moreover, these participants learned a bunch of new ways to help a woman in labor.

Non-negotiable: Two things that will help you labor longer, better

The following items are (in my opinion) the top two non-negotiable things that will help a woman labor, especially if her goal is natural childbirth in a baby- and mom-friendly hospital.

Non-Negotiable Item 1.  Drinking in labor.

Eating in early labor is a given.  For many women, early labor comes on slowly and lasts an average of 12 hours.  Contractions are mellow and irregular.  Women and their partners are advised to rest, to walk, to eat, to smooch, and to enjoy this last bit of baby-free time in their lives.

In early labor, mom is preparing to run a marathon.  She is stretching her strongest muscle: the uterus.  Would you run a marathon on an empty stomach?  Of course not.  Eat.  Eat carbs.  Eat some protein.  Eat whatever sounds good to you.  If nothing sounds good to you, try some toast.

Eating in active labor is a bit harder.  If mom is at home, and she is hungry, she should eat.  At the hospital, eating may be restricted or downright forbidden.

Now, this is the non-negotiable part: After every contraction, take a sip of water.

Especially if it is your intention to have a hospital birth naturally, with no drugs and minimal interventions, drinking water is key.

In many Baby-Friendly™ birthing facility hospitals (such as the ones in my area), the standard procedure is, upon admission, to start a heparin lock, or hep-lock.  A hep-lock is a needle and a catheter with a lid on it.  The needle goes in the vein, and the rest of it is taped to the arm so that it stays put when mom moves around.  Depending on the obstetrician, the IV fluids are negotiable, and mom and her partner can ask that nothing is hooked up to the hep-lock until something is needed.

The doctors' argument for a hep-lock is that if there is an emergency situation later in labor (e.g., in transition) that the IV has already been started, as it can be more difficult to find the vein in a stressful situation.  Some activists argue that having a hep-lock started creates emergency situations: a doctor is more likely to intervene when the vein is open than if the extra work to start the IV still needs to be done.

Times that IV fluids are needed (and required) include, in order of severity, when mom is severely dehydrated and unable to drink, when mom requests an epidural, and when preparing for a Caesarean section [3].  Notice that I say that these are required cases of IV fluid use.  Some obstetricians give IV fluids routinely.  In routine cases, I suggest you argue for a hep-lock, or no intervention at all, if possible.

The reason I harp on routine use of IV fluids so much is fourfold.  First, the IV and associated IV pole hinders mobility.  It is harder to move around and change positions, harder to find comfortable positions, harder to engage in hydrotherapy (i.e., bath tub or shower), when wheeling around a pole.  Second, in many cases, when IV fluids are being administered, women become over-hydrated; if there is glucose in the IV, the baby often shows signs of hyperglycemia before birth followed by hypoglycemia after birth.  Third, in many cases, when IV fluids are being administered, women are prevented from eating and drinking, "just in case." I discuss this in the paragraphs that follow.  Fourth, and finally, an IV is an often-unnecessary intervention, so I disagree on principle.  Any intervention, especially an unnecessary one, adds to a passive maternal mindset, making her feel that labor is something that is done to her, against her control, rather than something that she is doing.

Back to drinking water.  Drinking during labor prevents dehydration, thereby helping to prevent routine use of IV fluids.

Although it is impossible to name the cause and the effect, the association exists: Women who were advised to eat and drink in labor had a lower rate of instrumental birth (13% for those that ate and drank, vs 24% for the women that did not) [1].  Some doctors do not allow women to eat or drink in labor for various reasons, such as aspiration in the possible case of surgery, but the aspiration myth has been debunked again and again [2].  We are just waiting for obstetricians to get on the bandwagon.

Non-Negotiable Item 2.  The "cleansing breath."

The "cleansing breath" (pictured to the right) is a breathing technique originally taught in Lamaze childbirth education classes [4].  It is also known as the "relaxation breath" and the "good-bye breath."  The basic idea is relaxation during (and between) contractions.  When she feels a contraction coming, the mother takes a deep breath, visualizing her entire body going limp when she exhales.  This prepares her body for the contraction ahead.  The contraction comes, taking her whole focus.  When she feels the contraction is leaving, she takes another deep breath and exhales, breathing away the contraction, and issuing it a much-needed farewell.  Keep in mind there are only about 314 contractions in one full first-time labor.  Each cleansing breath gives a welcoming hello and a parting good-bye to one of these 314.


Follow up the cleansing "good-bye" breath with a sip of water.  Eat, drink, and be mobile in labor.  In particular, drink to stay hydrated.  Birth partners, take note!  Offer a sip of water after every contraction.  Breathe to stay focused and relaxed at the onset of a contraction, and breathe to say good-bye after the contraction fades.

This discussion may have gotten you thinking about your own hospital's policy: What does your birthplace do routinely, and what leeway do you have with your birth plan? Check out this online list of questions to ask your obstetrician and hospital or birth center.  Strike up a conversation with your OB. And remember that the object of the game is to be well-informed and well-intentioned.


[1] Scheepers, H. C., Thans, M. C., de Jong, P. A., Essed, G. G., Le Cessie, S. and Kanhai, H. H. (2001), Eating and Drinking in Labor: The Influence of Caregiver Advice on Women's Behavior. Birth, 28: 119–123. doi: 10.1046/j.1523-536X.2001.00119.x

[2] Ludka, L. M. and Roberts, C. C. (1993), Eating and drinking in labor: A literature review. Journal of Nurse-Midwifery, 38(4): 199–207. doi: 10.1016/0091-2182(93)90003-Y

[3] Midwifery Today E-News. (1999), Heplock or IV?  Midwifery Today E-News, 1(37). September 1999.

[4] Hurprich, P. A. (1977), Assisting the couple through a Lamaze labor and delivery. MCN: The American Journal of Maternal/Child Nursing, 2(4): 245.

How many contractions are there?

There are only so many contractions in labor.  Would you like to do the math for first-time moms?  Great, because I would!

Early labor is widely variable, and can last anywhere between a few hours and a couple days.  Does this sound like a long time?  In early labor, contractions come and go with no particular pattern, and are generally not painful.  Sometimes labor can start and stop, allowing you to rest and sleep.  Women are encouraged to eat, rest, and do distracting things like watch movies, play cards, and go on short, mellow hikes.  The time between contractions can be anywhere between five and 20 minutes, and contractions last under a minute.  Let us assume, without loss of generality, an average of four contractions an hour and an average duration of early labor of 24 hours.

1st stage, early labor contractions: 4 contractions per hour × 24 hours = 96 mild contractions

Active labor, the second phase of the first stage of labor, has an average duration of 12 hours.  Contractions are more intense, and women often must summon their concentration through each contraction. Distraction is no longer an option, and women should be supported at all times by thoughtful caregivers.  At the onset of active labor, a woman's contractions are five minutes apart (60/5 = 12 contractions per hour), and by the end, they are around three minutes apart (60/3 = 20 contractions per hour).  The average of these is four minutes apart (60/4 = 15 contractions per hour).

1st stage, active labor contractions: 15 contractions per hour × 12 hours = 180 contractions

The final phase of the first stage of labor is transition.  This phase can last minutes or a few hours, but we can assume one hour (the longer end of average).  Contractions are up to two and a half minutes apart (60/2.5 = 24 contractions per hour).

1st stage, transition contractions: 24 contractions per hour × 1 hour = 24 intense contractions

The second stage of labor, or pushing, lasts between 10 minutes and three hours.  After three hours, the doctors start getting antsy to intervene (though some will let you continue pushing if progress is being made and the baby is not showing signs of distress).  Pushing contractions are different in frequency and quality from first-stage labor contractions, and many women find them easier to tolerate because, rather than working against them to relax, they work together with their bodies.  Let us assume an hour of pushing, with contractions every five minutes (60/5 = 12 contractions per hour).

2st stage contractions: 12 contractions per hour × 1 hour = 12 contractions

The third stage of labor, during which the placenta is delivered, lasts about 10 minutes.  Irregular, infrequent contractions can continue for hours or days.  Women tend to forget about the third stage of labor because baby's out, and these contractions are very mild compared to even active labor contractions.  But for the sake of completeness, we will factor these in.  Let us assume 10 minutes of contractions, five minutes apart.

3rd stage contractions:  10 minutes / 5 minutes apart = 2 contractions

The total average number of contractions throughout a first-time labor, then, is 96 + 180 + 24 + 12 + 2 = 314 contractions.  Think you can do that?  After every contraction passes, issue it a "good-bye" or cleansing breath, and tick down your counter.  That is one contraction that is never coming back, and you will never experience again.

Wednesday, September 15, 2010

Cow Clicker: Heuristic Evaluation

I took the liberty of running a heuristic evaluation on Cow Clicker.  The set of heuristics I am using is from Spyridon Papaloukas' paper, Usability Assessment Heuristics in New Genre Videogames.  Descriptions of heuristics are taken verbatim from the text of the article.

The rating is Nielsen style, 0 to 4, where
 * 0: no problems,
 * 1: minor or cosmetic violation,
 * 2: moderate violation.
 * 3: severe violation, and
 * 4: show-stopping terrible stuff.

1. Customize game, network and environment settings: The videogame should allow players to customize the settings so that the game accommodates their individual needs.

My score: 0
My comment: You can customize cows!

2. Information about game, players and online friends status: Users should be provided with enough information about game (status character, level, health, etc) but also about other players and online friends in order to play in a cooperative manner as in real life.

My score: 0
My comment: I can click my friends' clicks! If only I had friends!

3. Training, help and suggestions: The videogame should provide interactive training and recommended choices, i.e. regarding new genre videogames should advice players the most  appropriate clothing or the most suitable space arrangement for a more efficient or enjoyable game.

My score: 1
My comment: I'm not quite sure where to place my friends' cows in my pasture.  Is there an optimal placement?  Does the cow facing the tail of my cow fare poorly due to out-gassing?  Does my cow enjoy facing colorful cows?

4. Control of actions: The game should respond to input devices in a way that mirrors the real world. Computer controlled units should respond in an ordinary manner.

My score: 2
My comment: Clicks are clicks. However, why does the page reload post-click?

5. Challenge, fun, pleasure, fantasy: The game should provide fun and challenge. The players should be able to live their desired “reality” in the fantasy world of a videogame. Pleasure should be one of the most important elements of game.

My score: 0
My comment: The challenge is in convincing my friends not to hate me.  And in finding all the back-issues of my friends' click feeds.

6. Minimize memory requirements: Abbreviations should not be used. The players should not be asked to count resources like bullets and life and they should not have to memorize the level’s design. Area maps should be easy to learn and should be intuitive to use.

My score: 1
My comment: It was difficult to ascertain the significance of mooney at first.

7. Clear goal, conditions: New genre games need special equipment and in some cases suggestions are required on how to use it more efficiently. The goal of the game must be clear, so the player do not feel confused.

My score: 0
My comment: The goal is overwhelmingly clear.  Its simplicity is what makes the game efficient.

8. Visual representations: Visual representations, such as maps, icons, and  avatars, are frequently used to convey information about the status of the game. Visual representations should be designed in an easy to interpret way, and so that users can   differentiate important elements from irrelevant elements.

My score: 0
My comment: The cow looks like a cow (except for Cobra Cow; what's up with that?); the pasture looks like a pasture.

9. Social networking, socializing and gaming: A game in a social network should support all the tasks, which facilitate the communication and socializing of players. The game should have “shared” versions or “shared” applications in order to direct “social networking friends” to tasks that enhance socializing.

My score: 0
My comment: Hard to say if I'll have friends after playing this game, but that's another issue...

10. Health, day-to-day life and gaming: New genre games should help on player’s mental and physical health, using specific equipment and applications.

My score: 4
My comment: Playing Cow Clicker reminds me of how large and bovine I am becoming, sitting at the computer --- yet the game compels me to keep at it!  It sends the wrong message, Ian, the wrong message!


Thursday, September 9, 2010

Toddlers and Judaism: an apology

L'Shana Tovah --- happy new year!  Today is Jewish new year, Rosh Hashanah, literally meaning "the head of the year."  The year is 5771, which counts the number of years since G-d created the earth.  On this day in history?  G-d created Adam.

Rosh Hashanah has special meaning for us in our family.  Twenty seven years ago, my grandfather died on the Jewish new year, which coincided with September 9.  Every year since becoming an adult, I go to Rosh Hashanah services, waiting for the mourner's kaddish.  This is a time for the community to come together and support each other.  Mourners seek solace in the community; the individual mourner is joined by his peers as the whole mourns together with this beautiful prayer.

The night before Rosh Hashanah, I was discussing with my husband the logistics of attending services at a local synagogue.

"You could watch the kid while I ---"

I was going to say, while I go to services, but I interrupted myself.

"No, that's stupid," I continued.  "Kids should come to services.  Of course kids are welcome there."  Judaism is about family.

"Of course, you should bring him," my husband replied.

So this morning, my son and I went to services at a synagogue that I had never attended before.  On their web page, they call themselves a "renewal" community, preaching tolerance and acceptance of all races, orientations, and genders.  As is common with Jewish groups in my town, there is no synagogue owned by the people.  Instead, the community rents a space from a Christian church, and holds services there.

When we walked into the space, my kid on my hip, I did what I had always done in services.  I walked in, took a prayer booklet, and sat down in the back row.  Prayers had begun about 45 minutes ago.  The cantor, a woman with long uncovered hair, sang slowly, with great feeling, into a microphone.  Next to her stood a man with a prayer shawl, leading the services.  Around the room hung laminated signs, calling participants to "respect the sanctity of this space."  Men and women sat mixed on padded seats.

I glanced around as my son pulled down my shirt and started to nurse: no other kids were in the congregation.  This was unexpected.  My past several Jewish events were in the home of the Chabad rabbi and his family.  The rabbi's children were an integral part of services.  Not only are children welcome, they are mandatory: how else do you expect the Jewish people to pass down thousands of years worth of knowledge?  How else do you hand down the oral Torah, unless you engage the children from a young age?  Do you think the "mixed multitude" wandering the desert had no children?  The Passover ritual meal even scripts in what to say to children, and which questions they should ask --- because children sit at the same table as adults, learning from the adults' actions and their rituals.

Suddenly, as if on cue, a small group of about six school-aged kids were ushered in.  They sat on the floor in front of the cantor and her male counterpart.  Everyone sang the shma.  My son hummed along.  The entire song is one line long; it is sung once.  It takes about ten seconds.  The song ended, and the kids were ushered out.

When he finished nursing, my son started looking around and telling me in a very sweet voice about the trolley and the bus and the train.

Five thousand heads turned and looked at me, scowling.  Scowling!  I had never seen so many hairy eyeballs before.  My son and I were violating the sanctity of their space.  I picked up my son and ran out the back door.

Outside, I saw a sign advertising child care for the services, and decided to go check it out.

The room was too large and too barren for those same six school-aged children that we had just seen in the congregation room.  Everyone sat in a tiny circle with their mothers, except one kid, clearly too old to be in child care.  Maybe he was helping out.

"Were you there for the shma?" the leading lady asked me, after the standard introductions.  The circle expanded about three inches to let us sit down.

"Yes," I replied.  "That was just before I got all the dirty looks."  For some reason, I felt like bursting into tears with those words.

"Oh," moaned another woman without even looking at me, "we don't take responsibility for those."

My son and I sat in the circle for a full five minutes before he got up and ran outside.  Bored and growing tired, he pointed to the street.

"Bus," he said.  "Home."  So, without a word or a look back, we went home.  I missed the kaddish, but asked myself if this is the congregation for me.  Do I want this community grieving with me, with my family?  Would we feel supported by them?

For a congregation that preaches equality, acceptance, and community, this one was lacking.  The way a congregation treats children speaks volumes about how it sustains itself spiritually.  This congregation cares so much about its members and their spiritual health, it lacks the foresight to ask: who will continue on this tradition of spirituality when the current members are gone?  "Arrogant, childless hippies," I cursed.

Rosh Hashanah is not about meditation and calm solitude.  It is about jubilation, sharing, noise, and ushering in the sweet new year in the community of family and friends.  It is about forgiveness and hope for a brighter, better, stronger, more pious future.  There is no room for selfish rumination.  As Wendy Mogel points out in The Blessings of a Skinned Knee, the synagogue is a place of worship, but the simple kitchen table is an altar.  There is nothing more holy than family.

I wanted my son to see the people gathered, humming blessings and songs, bowing and rocking.  I wanted him to hear the sounds of prayer; to hear the shofar.  I wanted him to feel what I feel every year around this time; I want this experience to be an integral part of who he is, as it is an integral part of who I am.  But our experience fell short.

With this explanation I humbly ask forgiveness from my parents, who were counting on me to say my grandfather's name on the anniversary of his death.  I missed the mourner's kaddish, and for this I am sorry.  Yom Kippur is in a week; we will return to Chabad and remember him then.

Sunday, September 5, 2010

Mineral deficiency and vasospasms

When I was a few months postpartum, I started experiencing vasospasms.  A vasospasm is a painful pinching of the blood vessels.  Mine were in my nipples, probably caused by prior trauma (in the first few months).  I could watch the tips of the nipples turn white, then blue, then pink, then repeat the cycle over the course of about half a minute.

I went to a lactation consultant.  She said there were two options.  The first was to take a magnesium supplement with calcium, about 1000 units a day.  The magnesium would help with the spasms, and the calcium would balance the magnesium, which could cause bowel issues.  The second option, if the first did not work, was to get a prescription for nitroglycerin cream.  Nitroglycerin is a highly explosive substance, and is usually used to treat heart patients.  

When I saw my doctor later that week for my son's well-baby visit, I mentioned the vasospasms and the lactation consultant's recommendation.  My doctor rolled her eyes, as if to say, "Nursing is uncomfortable. Deal with it."  Without even looking at the problem area, she said, "You don't need a prescription."

I picked up some cheap calcium-magnesium-zinc tablets at Trader Joe's, and took them for a few weeks.  The symptoms improved, but did not vanish; eventually, I stopped taking these giant pills that made me gag because I stopped getting improved benefits from them.  And I hate gagging.

Fast forward about a year.

I went to my chiropractor last week.  Each week, I complain for several minutes about my weekly ailments.  I have inherited quite a few from sleeping on the Japanese futon on the floor, on my side, with a pillow that had probably deteriorated several years ago; from carrying around my 27-pound toddler and associated accessories; from sitting, hunched over a laptop, in cafes around town while typing furiously my thesis and papers; from watching back-episodes of Project Runway and Covert Affairs while sitting in awkward positions, trying to simultaneously hug my husband, cat, and a slice of cheese toast.

On this visit, I complained about a neck spasm which, as Murphy would have it, started the day she went out of town, and cleared up before she returned the following week.

"Are you taking your prenatals?" she asked.

"Yup," I replied, proud.  I did not always take my prenatal vitamins while I was pregnant, because they made me sick, as did everything I tried to put in my mouth.  Now, as a nursing mom, I took these vitamins religiously, and even noticed a marked change when I accidentally skipped a day.  I would feel sluggish, tired, unhappy, and like I was on the verge of getting sick.  It is like telling your dentist that you do, actually, floss daily.  I was very proud.

She looked straight at me, stopped writing in her notebook, and said, "Are you taking a calcium supplement?"

"Uh, no... my prenatal ---"

"You have to take a calcium supplement.  You are going home with a bottle of calcium today," she scolded.  She explained that muscle cramps are symptoms that my calcium supply is depleted and my body is stealing the calcium from itself to generate the milk that my son still drinks.  The calcium that is generally sold in US stores is of poor quality, hard for the body to digest and incorporate.  You have to be very choosy about your supplements, and preferably get them from Canada, where the vetting process for these consumables is much more strict.

So, I picked up a large bottle of chewable calcium ("Calcium candy," my chiropractor said. "They're like Sweet Tarts."), infused with magnesium and vitamin D.  I have been taking them for about four days and I feel better.  Maybe it is psychosomatic.  But I have been having almost no vasospasms --- which I did not even notice I was having, because vasospasms are a drop in the bucket of my daily body aches at this point --- thanks to the magnesium that came in the pill.  I feel limber; my back is not as uncomfortable.  Plus, these supplements tend to, erm, cleanse the body frequently.

Since having my son, I no longer have the luxury to listen to my body.  Where before, my body needed to whisper a problem to me, or just hint at it, and I would hear and obey, now, it needs to scream.  Before, my body could suggest, "Perhaps you should not lift that," showing me with a gentle twinge in a toe.  Now: "You sleep wrong! Raraararr!" it yells, when my muscles are tense for three days and I cannot turn my head because of the alignment of my lower neck.

The moral of the story is to stay on top of the body's needs.  The nutrients my son gets from my milk come from somewhere; until very recently, they had been coming from my own body.  And if I cannot hear my body's needs, I should listen to my chiropractor.  She seems more on top of it than I am!
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