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.

References

[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.