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

Friday, September 23, 2011

Why I'll never be a nurse

I'll be honest.  My research direction has been making me curious.  Could I be a nurse, or a midwife, or even an obstetrician?  I am already a doula, and I have more book-knowledge of labor, birth, and the early postpartum period, including surgery, than many of the nursing students I have met.  Each time I have attended a birth so far, my curiosity was tickled: is this for me?

When I was invited to attend a labor support workshop, part of a nursing student course in midwifery taught by one of my research collaborators, I was excited.  Walking up to the building and passing dozens of men and women dressed in scrubs, walking quickly along both sides of the sunny street, engaged in conversation or talking on cell phones, I thought: with a small difference, a slight twist of fate, that could have been me.

To the workshop I arrived on time, took a seat, and looked about the room.  It was filled with students just like me: young (I would like to think I am young, despite being older than most of the students in the room), energetic, eager to learn.  I asked around and learned that everyone had already chosen a specialty.  The woman sitting beside me would become a nurse practitioner, the man beside her will be an "acute" nurse (that is, working with very ill patients), and the woman across the table will go on to an administrative position.

I was interested in this, and was especially interested in the students' experiences in different classes.  One student talked about her last class, which was about oncology.  I liked the idea of the "grand tour" of specializations that every student submits to, no matter his or her interest, and thought that something similar for computer science (or, more broadly, computing and electronics) would be excellent.  I knew I would be a computer engineer even before I took my first computer engineering course -- but the course sealed my love and I declared my major.  But other students were not so lucky to have found their niche as smoothly as I did.  Would they have benefitted from a grand tour, exposing them to electrical engineering, programming languages, assembly language, high-level database design, and robotics?

Later, I asked my colleague, who was teaching the class, how it is that everyone already knows what they will be at the end of the three-year program.  She explained that students choose their specialties before they even apply.  Once applied and accepted, they cannot switch, and if switching to another program (such as midwifery, as often happens as a result of this birthing class), they must withdraw from the program and re-apply.

"Yikes," I said.  "That's heartless!"

"Yes, it is difficult," she replied.  "There is no way to know for certain before you apply what you will be good at, or what you will even enjoy as a profession."

I spent all day in the hospital classroom among the students learning about birth support, and what it means to support a woman in birth.  Having undergone doula training and having read everything possible on the subject, I could answer the rhetorical questions about the mother and how to support her.  But I was pleased to learn about the relationships between the clinicians and to hear, from a midwife who practices in a hospital, how the medical pieces of birth fit together and work.

I did not know, for example, about the rigid hierarchy that exists between nursing students, nurses, clinician instructors, and providers.  But on learning of it, I thought it was lovely.  Every student that belongs in the program occupies a very specific place in it.  As a student, you always know where your place is and to whom to turn with questions.  And whom you mentor.  You know where your responsibility lies, and (more importantly) where your responsibility ends, and where you escalate your issue or question to someone else, someone farther up the hierarchy.

In computer science, we do not have this.  You wade through your program, sometimes overtaking your peers, and other times falling back.  You graduate, sometimes ahead of your peers, sometimes behind them.  You get a job, and depending on the work and the company and the culture, you are left to fend for yourself.  You are given a stack of tasks, sometimes poorly-defined, and are left to figure them out on your own, because you are, after all, a college graduate.  You are a computer scientist.  When you have questions, you ask anybody and everybody and hope for the best, or you ask no one at all.  Mentoring relationships are forged, usually accidentally, sometimes forcedly -- and frequently, not at all.  The stereotype of the computer scientist working alone, always alone, is sadly true, but never desired.  Nobody likes to work in a vacuum.

So, I thought these relationships which were so rigid and unquestioning were also beautiful, like lace that ties all these students who will be graduates together and to their peers and superiors.

As I looked around the room in the second half of the workshop, I saw some faces still eagerly listening, taking it all in.  Other faces were contorted in horror -- the horror of the memory of what a woman's vagina actually does.  The explanation came moments before.  And then it hit me: Nurses learn not to fear their jobs.  They do not come in to the practice unfearing.  First they learn to conceal their fear, and then they learn not to fear.

At the end of the workshop, I left for another hospital, where I attended a volunteer doula meeting.  I am in the process of becoming a volunteer with this teaching hospital (in which many of the students from the workshop will be training).  In the meeting, issues came up which highlighted some doulas' misunderstanding of the nursing relationship to the patient and to the provider.  For example, doulas do not always understand why certain procedures are necessary and argue on behalf of their clients in inopportune ways.  Continuous fetal monitoring is always required with an epidural because the baby is at risk when drugs are crossing the placental barrier, yet sometimes, through their own ignorance and not through any malicious means, doulas may argue with the nurses.  I was surprised to learn this because I thought as a doula, my job is not to argue with anybody, and especially on behalf of the mother -- to create a calm atmosphere regardless of the situation at hand.

But really, what the doula meeting taught me was that doulas are seriously unprepared.  A workshop covering the basics of nursing and the clinician relationships is absolutely essential.  I am glad I profited from such a workshop, and wish more doulas had a similar opportunity.

I came home that night exhausted.  I had spent the majority of the day in hospitals.  The monotony of artificial lighting, artificial air, and artificial manner (for example, nurses hiding their boredom) was too much for me.  All this talk about birth and babies, a topic that I absolutely adore and consider a fundamental cornerstone to my own work, had, for the first time ever, completely drained me.  At home, I was conscious of the desire to reunite with my computer, to pull out my notebook, and to design, code, engineer, and think.

And for the first time since embarking on my research, I realized: Nursing, midwifery, and obstetrics -- maybe these are not for me.

I am a technical woman.

Five do-overs since my first Grace Hopper Celebration for Women in Computing

Grace Hopper Celebration for Women in Computing is an annual event bringing together thousands of women from different technical computing specialties and at different stages of their career.  Attendees include undergraduates considering computer science as a major, graduate students choosing their research direction, recent graduates looking for a job, women in industry, professors, researchers, and recruiters.  It is a diverse, funky, exciting, inspiring, and nurturing environment of two thousand women, all of whom are smart, brilliant, beautiful, and different in their own right.

This year will be my fourth time attending, which makes me a Grace Hopper veteran.  I first heard about Grace Hopper Celebration from my room mate from CRA-W Grad Cohort -- a similar but much smaller mentoring program for graduate student women -- when I asked my room mate how on earth she knew all these people.  She was saying "Hi," calling people by name, and giving hugs to everybody!

"How do you know everyone already?" I asked her.

"Some women I know from last year's Grad Cohort," she replied.  "But some women I see basically twice a year: at the Grad Cohort and then again at Grace Hopper Celebration."

"What's that?" I asked.  Casually hiding her surprise that I had neer heard of Grace Hopper Celebration, she explained it to me, and that night in our hotel room I looked it up and bookmarked it.

When Grace Hopper Celebration came around that year, my advisor asked if there are any women that would like to go, because our university was a sponsor and received a few spaces for student attendees. Of course, I replied immediately in the affirmative, and off I went!

Now that I have been three times to Grace Hopper Celebration (this year will mark my third time as a contributor) and twice to the CRA-W Grad Cohort, I can look back on my first Grace Hopper Celebration visit a bit critically.

My first year, Grace Hopper Celebration was held in Keystone, Colorado, a small resort town situated in the mountains among an aspen forest.  The trees were just starting to turn in ones and twos: blots of color among a sea of green leaves.  I was driven from the airport in a shuttle and looked out onto the picturesque landscape with wide eyes.  I was young, impressionable, and pregnant.

Yup, I was about 24 weeks along in my pregnancy.  I knew I was carrying a boy, and I had just returned from a trip abroad -- a delayed honeymoon -- before having time to buy clothes that fit me.  My belly had just started getting too big for my pants.  It happened so suddenly that I was ill-prepared, wardrobe-wise, for the change in my figure.  I was a hot mess, unbuttoning my jeans and praying that my fitted t-shirts did not bust into holes stretched over my growing belly.  When my mother saw me at the airport on my return from Grace Hopper, she was shocked at my fashion sense, but at the time, I figured that is just an extension of the typical graduate student lifestyle.  Right?  Please tell me I am right.

Anyway, back to the point -- I could have done a better job.  As an early(ish) graduate student, my main role was to be receptive to mentoring and to meet people that would help me in my career path.  I see that now, in hindsight, but at the time I did not recognize these goals.  Here were my top five mistakes from the first year.  Every year I go back, I get a do-over and do my best to avoid these.

Do-Over #5.  Eat lunch and dinner.

At CRA-W Grad Cohort, one of the rules was that no two women from the same university could sit together at lunch.  You had to learn to network, and to meet other women.  But here, at Grace Hopper Celebration, there was no such rule, and even if there was, there is no way to enforce it with 2000 attendees.  So attendees would sit with the people they knew more often than not, and I, seeing this social norm, followed suit.  Not a good idea.  Now I know that it is best to sit at a table where you know no one.  Even better: sit at a table where you know no one, and everyone is different from you.  Is everyone older?  They have more experience.  Is everyone younger?  Maybe they have questions.  But if everyone is exactly like you, there is no way you can broaden your experience.  Challenge yourself.

Do-Over #4.  Use the room mate.

I was at Grace Hopper Celebration on an underwriter scholarship, and, like all scholarship recipients, I had a room mate.  Actually, in this year, we were in a three-room cabin in the mountains of Keystone, Colorado, and I had two house mates.  My house mates were amazing.  They asked me about pregnancy and married life, about the proverbial work-life balance (as if there is one), about what I will do once I have the baby (hint: stay in school).   On our last night in Colorado, we all went shopping to the outlets nearby and my lovely room mates bought me a shirt that actually covered my entire front.  Maybe it is silly, but I was moved.

But most of the day, my house mates (who knew each other) would be off on their own, and, in pregnancy-related discomfort (more on this later), I left them to themselves.  I did not go to see their posters at the poster session; I did not ask for introductions to other women; I did not sit with them and their colleagues at lunch.  But this was wrong.  Use your room mate (or room mates, if you are lucky enough to have two) -- use them as mentors if they are more experienced at Grace Hopper Celebration than you are; use them as friends if they are new like you; use them as a sounding-board for your elevator pitch for your research.

My room mates approached me on the second day and said, with a sly grin, "We are thinking of taking a drive up to the summit, instead of one of the sessions.  Are you in?"  I considered for a moment, wondering if it is OK to skip sessions, and if we could leave the conference grounds without arousing suspicion among the organizers.  Hesitating a little, I said that it sounds like great fun, and that I would certainly come.

As we arrived to the summit, the weather shifted dramatically, from cool and clear autumn to cold and foggy winter.   Not another person and not another vehicle was within sight: it was just us.  It began to snow in large, fluffy flakes.  The electricity in the air made our hair stand straight up, and lightning bolts noiselessly crashed all around us.  We giggled and photographed and huddled in our insufficient jackets -- and bonded.  We formed relationships which would survive the test of time and geography -- relationships we could later fall back on in our professional and personal lives, because we had this shared experience.

Do-Over #3.  Couch potato networking.

During the course of Grace Hopper Celebration, my baby, whom I called Galahad ever since knowing I was pregnant, grew as well.  I would like to think it is because of my rock hard abs that, one day into the Celebration, I started getting rib pain.  My ribs were expanding to fit my high-carried fetus and I was in pain from the pressure in my ribcage from about noon until I went to bed every night.  I did not tell anybody (except my amazing room mates) because I had never enjoyed complaining, especially to strangers.  Even strangers that are there for the express purpose of caring for and mentoring me.

Half the day, my ribs would hurt so much that I could not sit up.  Sometimes I would go back to my room and lie down; other times, I would sprawl out sideways on one of the low arm chairs in the conference area and try not to moan.  Both of these were missed networking opportunities.  Now I see that it is OK to sprawl in pain rather than attend a session, as long as I am doing something to further my career.

See, I had no idea where my academic career was going.  Here I was, not even half-way through my first pregnancy, not even two years through grad school, and with no idea where my research interests were.  Every class I took was fascinating for the first three weeks; every project I undertook was interesting only for the first half.  I knew I was a fantastic teacher but had never undertaken any serious research project.  I knew I wanted to be a professor eventually -- but a professor of what?  How do you find the one thing that really turns you on?

These are all questions that, though they cannot be answered by someone else, they can point you and your mind and heart into a direction.  Other women's experiences can influence how you experience yourself.  Maybe I am getting a little hippy-dippy.  But my point is that I was not using this time to the best of my abilities.  I could have been meeting women in a higher position than myself and asking for advice; I could have been meeting my future mentor; I could have been learning with others, rather than suffering alone!

Do-Over #2.  Tell your secret.

Maybe it was the pregnancy hormones talking, but I posted an anonymous advertisement on the bulletin board:
Looking to connect with other pregnant graduate students and those with kids.
I added my e-mail address and hoped for the best.  The truth is that I did not know what I was looking for.  Support?  Advice?  Encouragement?  I did not have any concrete questions but I wanted to know that I was not alone, that my experience was not unique.  In some ways, I suppose, I wanted validation.  I wanted someone to say, "I know things will get rough, but you can do it, because I did it."  Though I did receive a few notes, mainly by other participants pinning replies to the same bulletin board, I never replied to them, in part because I did not know what I wanted to say, and in part because I did not want to give away my secret.

I had only told my room mates, and mentioned it once at lunch.  One of the women, another student, lit up: "Do you have maternity leave at your university?"  I answered honestly that I did not know.  She persisted: "You know, it should be covered by the union.  They bargained for it just last year.  It is brand new this year.  You should look it up."  After lunch, she and I both went to the computers and found the relevant sections.  She was glad to help me, and I was glad for the help, because until then, I had never considered my rights and my future as an employee of the university.

It was not until the last hour of the last day, when several of us were loading the bus, that I told one more person about my pregnancy.  She was a young woman with a large baby, and introduced herself as a professor.  We chatted briefly about pregnancy, and exchanged information.  It seemed so natural and inconsequential at the time -- especially as I had such a reverence for professors because of what I now see was mild impostor syndrome -- but I was calmed by her easy nature and friendly manner.  This small event which I had put out of my mind as an impossibility because of the difference in rank, this easy exchange of words and information, this event was probably the best thing that happened to me at Grace Hopper Celebration that year.  Today, the professor who befriended me continues to mentor and support me through my final years of graduate school.  I told my secret to the best person I could possibly meet.

Do-Over #1.  Meet the speakers.

I had attended a great many talks, but one in particular still speaks to me today.  It was a talk I had heard before, at CRA-W, given by a graduate student that had changed direction several times in the course of her studies.  She was explaining the same feelings I was having:  She would take an introductory class and enjoy it immensely, but not enjoy the follow-up class.  It took her a long time to find a dissertation topic.  She explained several ways that dissertation topics come into existence: the extended course project, the advisor's list of unfinished work, the stroke of genius, and others.  She struck me as someone I would love to be friends with -- but she was so smart! so accomplished! What would I have to offer by speaking with her?

Wrong, wrong, wrong!

Now that I am also a speaker at Grace Hopper Celebration, I know that speakers are people too.  I love it when people attend my talks, and I love it even more when they stay afterwards to tell me that the talk was useful to them, my nervousness did not show, or even that my animation skills in the slides were top-notch.  Which, I assure you, they are not.  I love it when people tweet about my talk.  I love it when people come to ask me for advice, or ask for my contact information in the case they have questions about something I said.  I love just knowing that someone, somewhere, was affected by my talk.

I did approach this particular speaker, and I told her that I had heard her talk before and I really admired her.  She was surprised: "What, me?"  Laughing heartily, she chatted with me about grad school, clearly expressing that she considered us equals.  She and I are still friends today.

Since then, I make it a point to meet every speaker that inspires me.  Even if she is the president of some fancy corporation, or the first author of an influential paper, or simply the woman that said something that really resonated with me.  I introduce myself and say, "What you said just now, I really took to heart.  Thank you for a great talk."  If we happen to meet again, I can say, "We met at Grace Hopper last year.  I loved your talk."  This usually leads to an invitation to join her lunch table, which -- by the way -- I always gladly accept.

Friday, September 9, 2011

Violet's birth. Part 2: Fay gives birth.

Read Part 1 of Violet's birth, in which Fay negotiates with Dr. Kim in the weeks before her due date.

That night, the day of the NST and start of the 42nd week, Fay's belief in her body was reinstated as she lost her mucus plug and had some mild contractions for about an hour, but then they stopped.  I did a little dance of joy on her behalf, because I knew that her body was getting ready for it.

And that night, Fay and Simon went in to the hospital to have their NST.  With the nurse's help, Fay climbed up on the hospital bed, turned on her back, and --


"Did I pee?"  She wondered.  "Is it blood?"

She looked down.

Nope, not blood.  It was clear and odorless.  The nurse turned to her and smiled.  Fay's water had broken.  Simon looked on.

"I guess you're staying now," the nurse said.  "I'd better admit you."

Non-stress test (NST)
"Deliver, not rest."

Admitted to the hospital, Fay lay on the hospital bed and looked at Simon.  "This is it!" she thought.  The non-stress-test (NST) was beeping merrily on the cart beside her.  The nurse entered, and Fay said:

"I think I'm having a contraction. I can feel it in my back and my belly."

The nurse looked at the monitor.

"Doesn't look like it," she said.  "But we'll have to get them started four hours from now.  I'll bring the Pitocin."

Fay and Simon looked at the clock on the wall.  It was 11pm and they were exhausted.  Fay remembered my advice to her: sleep when you can in early labor.

"Can we wait?" asked Fay.  "Until morning.  So we can sleep and be well-rested for the Pitocin in the morning."

The nurse rolled her eyes.  "You came here to deliver, not to rest."

Simon spoke next.  "No, actually." He cleared his throat.  "We came here for a non-stress test.  We did not come to deliver."

Fay asked, "Can we go home?"

"No," replied the nurse, her voice raising in annoyance.  Collecting herself, she added:  "Well, yes, but you would have to sign this form in which it says you are leaving against doctor's orders.  What happens to you outside this hospital," she closed her eyes and spread her hands, palms up, for dramatic effect, "is out of my hands."

Fay and Simon looked at each other.

"We'd like to wait eight hours before Pitocin."

"What difference does it make?" huffed the nurse.  "If labor doesn't start in four hours, what makes you think it will start in eight?"

Fay and Simon blinked at her.

"Fine.  Fine!" she scolded.  "You can have six hours.  I will be back to check you in four hours, at 4am.  Then at 6am I will start Pitocin."

"Deal," Fay and Simon said, and breathed a sigh of relief as she waddled from the room.

Sleeping labor, and active labor

Simon slept on the roll-out partner bed.  And in her sleep, Fay had contractions.  She woke up for each and every one of them.  The pain radiated from her back, and with each contraction she would wake up and press her back into the bed with all her might.  The counter-pressure was a relief but the pain was exhausting and all-consuming.

At 4am, the nurse returned and checked Fay's cervix.  It was 4cm dilated.  The nurse was defeated.  Packing up her Pitocin bags, she left the room and left Fay to labor, quietly, on her own.

At 6am, Fay called me, her doula, to come.  In the meantime, I told her, get on all fours and have Simon squat over you, putting pressure on your back with his hands.  On your back in bed is the worst place to be.  And drink some water.  And try the shower.  Water on the back may feel nice.

The doula comes

When I arrived, Fay and Simon were in the bathroom, with Fay in the shower.  The room was hot.  I knocked and pushed open the bathroom door as steam poured out.  I closed the door behind me.  There was a floral scent of shampoo, and with each contraction, Simon would lean into the shower and press on Fay's lower back.

"The pain was easily ten times worse in the bed," said Fay.  "It was unbearable.  It is so much better here in the shower, but my back still hurts during contractions."

"Sometimes back labor is caused by the baby presenting in an odd way," I said.  "She's probably pressing with her head on your spine.  Being upright and leaning forward like you're doing will help the baby turn a bit."  When we get out, I thought, we will try hands and knees, kneeling, and lunging.

"Ohhhh," said Fay as a contraction hit, turning her back toward the hot stream.

"The bonus is that in this shower, you won't run out of hot water."  I smiled and Fay copied my smile.

I heard some noise outside the bathroom door.  "I'll be right back," I said and excused myself.

Pain scale. I just want to punch someone when I see one of these in labor.
How much does it hurt?

In the room, a nurse, Katie, was standing with another woman whom she introduced as one of the nursing teachers.  I told Katie I am Fay and Simon's doula, and Katie exclaimed that she was so cool with doulas, unlike some other nurses, and that we would work well together.  The shower turned off, and in a few minutes, Simon and Fay emerged.

Katie did her work, taking blood pressure and temperature readings and setting up the monitors to listen to the baby.

"I don't usually ask this," she said, blowing her bangs out of her eyes, "but, on a scale of one to 10, ten being the worst you could possibly imagine, how would you describe your pain right now?"

I rolled my eyes.  Here we are, Simon, Fay, and I, trying to keep Fay from seriously thinking about her pain, trying to keep her distracted and taking things one at a time, and now she is expected to put a number on her sensation.

"In the bed," answered Fay, "it was bad.  Like nine.  I can't imagine it being worse.  But in the shower the pain decreased tenfold; probably a four."

I stammered: "Can we, uh, not do that again?"

"Yeah, sure, it's just one of the vital signs," explained the nurse, who probably saw me rolling my eyes anyway.  "Temperature, blood pressure, pain level.  We have to take it every hour.  If you want, I can just fill in numbers from now on.  Six, seven, six, seven."

Simon and Fay nodded, watching me.  I nodded vigorously.

Katie pulled on a sterile glove and checked Fay's cervix.  Fay held Simon's and my hands.

"Five centimeters," Katie announced.  "I think it is great you are laboring normally," she said, not looking at anyone in particular, and added that natural labors usually are assigned to her because she is so awesome at "dealing" with them.  Then she started talking about what a "good" labor pattern looks like and how we can tell that we are "progressing well."  She pulled up a chart showing 1cm per hour dilation.  Simon looked on, and I, knowing that talking about expected progress is not encouraging, sat by Fay's head and talked to her about her night in the hospital.

"I'll be back in about an hour to take your vitals again," Katie said.  We thanked her as she left.

Counterpressure to lower back
Fired from birth support

We labored normally for several hours, changing positions frequently.  We tried every position that I could think of to try to alleviate back labor.  I coached Simon how to spread his legs, lock his elbows, and use his back to push on Fay's lower back during contractions as Fay leaned forward on a stack of pillows on the raised bed.  If his hands slipped, or he changed his grip, or he got the wrong spot, Fay would scold him for a good half of each contraction -- and then we would all laugh as the contraction eased.  Laughter brought on contractions.  Walking brought on contractions.  Touching Fay brought on contractions.  We joked that we could not do any of these things, and if we did, Simon would be fired.

Simon was fired from labor support eleven times.

At 10:30, just two hours after the previous cervical check, we had progressed to a heartening "6cm, almost 7."  Things were great.

But at noon, something happened.


We were sitting in the middle of the room, with Fay on the birth ball between contractions, Simon in the glider, and me squatting at Fay's knee.  We heard a noise next door.  It was a woman.  And she was screaming.  She screamed for what felt like an hour, though it must have been just a minute.  She would stop screaming only to take a sharp breath and then the blood-curdling scream would come again.  Under the woman, we could hear other people's loud, mumbled voices.

Fay looked at me.

"She is not doing as well as you are," I said, smiling.  "Those are bad noises to make.  You are making good noises."

The screaming continued.  Fay stared at me.

"She is probably delivering," offered Simon.

The screaming continued.

"Oh my God," said Fay, the color draining from her face.

"It isn't necessarily pain," I said.  "The sensation is overwhelming.  This is why she is screaming."  We all looked at the floor, waiting for it to stop.

The screaming increased in pitch for a split second.  We held our breath.  Then, the screaming stopped, and was replaced by tearful shouts: "Oh, my baby, my baby!"

I looked at Fay and smiled.  She was crying.  Tears were rolling down her face.  I looked at Simon.  He was pale.

We talked about it.  We talked about fear, and how we need to get past it.  About how the baby is coming today, and we are helping her come.  About how most women do not sound like that.  Fay did not talk about delivery.  She was trying not to think about delivering the baby, about pushing the baby out, about the woman screaming next door.

Fay was exhausted.  Climbing into the bed and rolling onto her side, she fell asleep in no time. Though I tried to convince Simon to sleep, he and I sat near each other and talked.  We would chat, and then Fay would wake up with a contraction.  We would rush to her: Simon to her back, me to hold her hand.  Then it would ease and she would drift off.  This happened infrequently: contractions slowed to a crawl.  Every seven minutes.  Every ten minutes.

The drill sergeant

At 1pm, I went to fetch the nurse.  Because contractions seemed stronger, though infrequent, and there was that electric feeling in the air, that particular odor that I have come to associate with transition.  Katie came back in and, checking, we were pleased to hear we were 7-8cm.  Which is almost transition.  It is close.

"I've had some women complete on the toilet," Katie suggested, meaning that women dilate the rest of the way, to 10cm, or "complete" the dilation.

"Try the toilet," Katie continued.  "Try the shower.  Try nipple stim.  We gotta get things moving."

Determined to do everything I can that we should get through this part, that is, transition, quickly, I got Fay out of bed (bribing her with getting back in it later) and we went to the toilet.  Then the shower.  Then the birth ball, with her legs spread wide.  I kept waiting for that contraction with the pressure on top which indicates real transition, but I did not hear it.  It did not come.

Acting as a drill sergeant, I sent Fay back and forth from the door to the baby warmer.  She did laps around the room, and I suggested she try some nipple stimulation.  She ate a little bit.  She drank water.  We tried effleurage, in which Simon gently rubbed Fay's belly to bring on contractions.  But contractions were still slow, and there was still no pressure at the top.
How to do effleurage in labor

An hour later, at 2:30pm, we learned that we had made no progress.

At 4, Katie returned with a vengeance.  She showed us the graphs again (and again, I distracted Fay from seeing them).  She talked about progress and how we were not making any.  And she gave Fay two options: an epidural, which would help her relax, and the relaxation which may bring on contractions again, or Pitocin, which would bring on contractions.

"But if I choose the epidural," said Fay, leaning on the bed, "wouldn't contractions slow down, and then I will need Pitocin anyway?"

"Maybe," said Katie.  "Maybe you just need to relax, that's all.  But it's possible that we will need Pitocin too."  She looked her up and down.  "See, we've been talking about this for about five minutes.  You should have had two contractions by now."

Fay stood up and started walking, rubbing her belly in small circles.  No contraction came.

"Look," Katie proceeded once she was sufficiently convinced that she would not sell the epidural.  "We can start you on the lowest dose of Pit.  We can turn it off once contractions have started again."  Again she brought up a graph.  "See, this is a woman that's already delivered.  This is her contraction pattern at 7cm, which is where you are."

"Are these Pitocin contractions?" I asked, recognizing the shape -- which looks markedly different than that of a natural contraction.

Katie checked.  "Yes, it is."  But she was not discouraged.  "But it doesn't matter," she pleaded.  "See, you should be having another contraction, right now.  I want you to have this baby vaginally.  I want to help you.  You have to let me help you.  What have you been trying?"

"We've been walking around," I said.  "Nipple stimulation.  Effleurage."

"Why did you stop the nipple stim?" Katie asked Fay.  Fay looked away.

"Walking around seemed to work too," said Simon.

"But it isn't working!" cried Katie.  "It is not working.  Fine.  What about Fentanyl.  It's a narcotic and it may help you relax a little.  We just have to get you past this hump."  Katie felt Fay's belly during a contraction.  "See, it's not very strong, either."  She sighed.  "Sometimes a mom needs some help to get over the hump.  Sometimes she just needs to relax, or a break from the pain.  Sometimes she needs Pitocin to make contractions stronger.  Sometimes the baby won't come at all, and she needs a c-section."

I winced.  Katie had made offhand c-section comments before, but I was too busy distracting Fay from the conversation to wince properly.  This time I winced.  Alluding to surgical birth to a laboring woman is akin to alluding to filet mignon to a calf.  For some women, it is a blow to her faith in herself.

Passenger, passage, and power

Contractions were coming in pairs: a big one, and a little one riding on its back.  Then seven minutes of silence.  This is called coupling, and is fine unless no progress is being made.  But if the labor is dysfunctional, which is, medically speaking, where we were heading, then it can be treated with rest (which we had done in the hour Fay slept), hydration (which we were doing), and everything Katie suggested: Pitocin, epidural, Fentanyl.

Coupling contractions can be a symptom of an occupit posterior (OP) position of the baby, or sunny-side up.  Other symptoms of an OP baby are back labor.  Which is why we had been trying so hard to get Fay's baby to turn.  Most babies, something like 70-90%,  that start out OP will eventually turn in labor.  We had hope.

Katie suggested, "We have one more thing we could try before Pit."  She left and came back with a package, a long tube inside.  "This is an intra-uterine pressure catheter.  It goes in next to baby's head in the amniotic fluid, and when you have a contraction, we measure the strength of the contraction in milligrams of mercury."
Intra-uterine pressure catheter (IUPC)

She paused to make sure we followed.  We did.

"Normal labor has three components.  The passenger, the passage, and the power.  We don't know much about the passenger.  We don't know how big she is.  Do we?"

"No, we don't," said Fay.

Katie continued: "Maybe she's malpresented.  Maybe she's facing funny down the birth canal."  She pressed her glasses up her nose, letting her blonde bangs fall into her face.  "We don't know much about the passage yet.  About the birth canal.  Maybe you aren't big enough to let the baby pass.  I don't know.  So we can try to find the power."

She held up the IUPC.  "We use this to measure the strength of the contractions.  We can use this measurement over time, over the space of several minutes and several contractions, to get an objective number called a Montevideo unit, an MVU.  If we have enough MVUs, we know that contractions are strong enough and that labor should be progressing -- and if it isn't, then one of the other things, the passenger or the passage, is stopping it.  But if we do not have enough MVUs, we can try putting you on Pit, to make the power stronger."  She paused.  "This is real, empirical evidence."
Position of intra-uterine pressure catheter (IUPC).

Now, hang on a second.  I am a newer doula, so I had not heard about the "three Ps of labor."  But I did know about the fourth P: Patience.  Sometimes it just takes time.  We had been patient, resting and walking and eating, at 7cm for three hours.  The clock was ticking since Fay's water had been broken for 16 hours.

Fay and Simon talked about it.  "Basically, our options are Pitocin, or IUPC and Pitocin," Simon concluded.  "Let's just do the Pitocin."

"Finally," Katie said.  "You are letting me help you.  I feel like I am doing something."

Fay, Simon, and Katie agreed on a dose of Fentanyl and the lowest dose of Pitocin, just to get past the hump.  Fay would still be allowed to labor upright, but intermittent monitoring was no longer an option.  Antibiotics were started because of the ruptured membranes.

Pitocin contractions were different.  They hurt more, and lasted longer, but they were not closer together.  An hour later, the dose of Pitocin was increased, and, the contractions still not any closer (though more painful), Fay asked for an epidural.

Katie started an IV, and we waited for the doctor, all the while taking one contraction at a time.

The doctor, an older man with white hair who seemed to be old enough to retire by now, came with his epidural cart and asked Fay to bend forward, achieving "the worst posture you could imagine."  He cleaned Fay's back, numbed it, and inserted the needle.

"Hmm," he said.  "Can you lean forward more?  I seem to have missed the epidural space."

I gave her a pillow to hug in her lap.

He stuck her again.  "Hmm," he said, withdrawing the needle.  "I hit the bone again," he said.  Simon's eyebrows raised, but he was quiet.

The needle went in again.  "Missed," he mumbled, perplexed.

"Look," he grumbled, having missed again, "just curl your back into a C."

Eventually, it made it in, and the pain from the contractions dispersed.  They were still coupling, so Katie increased the Pitocin.  They were still coupling.

Before she left, knowing her shift was soon over and we would not be delivering on her watch (as was secretly our plan), I asked her to transfer us to another nurse that would be patient and kind with us and try to get us back on the path of natural birth.  She said she would, but no promises.  Then, she added:

"The IUPC is your last resort, so keep it in mind."  She glanced at the door.  It was closed.  Katie lowered her voice.  "If your doctor comes in and tells you she wants to do a c-section, you ask her to try the IUPC.  Try to see if the power is sufficient, if the MVUs are enough to get the cervix opened.  Do you understand?"  We nodded.  "Good," she said, taking her leave.

A new hope

At 8pm, the sun was starting to descend outside the closed mini-blinds.  Fay drifted back to sleep, covered by a sheet and a blanket.  Simon, who still refused to sleep, and I were sitting under the window, talking about how good it was that Fay was getting rest.

A new nurse came in, introducing herself as Megan.  She was stouter than Katie, brown-haired, and was full of fresh energy.

"Hi, Megan," I said, and, meaning how Fay has been coping with labor, "we've been doing great!"

"Not really," she said, turning away from the computer with just her shoulders.  "You haven't made progress since 1pm.  Your labor has stalled."  She turned back to the computer and read the notes.

I looked at Simon and gestured that I clearly said the wrong thing.

Megan woke Fay to check her.  "Eight or 9cm," she said.

"There, that's progress," I suggested.

At this point, Simon went to take a break, and brought back food for me.  When he returned an hour later, Dr. Kim came, and Megan checked Fay's cervix in Dr. Kim's presence.

"She's a nine," said Megan.  Dr. Kim looked concerned, turning up the Pit again, and promised to check back in an hour.

The 11th hour

It was 10pm, 23 hours after Fay's water broke, when Megan and Dr. Kim returned.

"The contractions have spaced out, and they are moderate," Megan explained.  "Maybe the uterus is tired.  That can happen.  The uterus is a muscle, and muscles get tired."

Fay, Simon, and I looked at each other.  I nodded: it's true.  They do.

Dr. Kim pulled on a glove.  "Still nine," she said, withdrawing from under Fay's sheet.

"Do you know what this is?" Dr. Kim asked, holding up the IUPC that Katie described earlier.  We nodded.  "I'm going to use this to measure the strength of your contractions.  We will see what is happening."

Meanwhile, Megan took Fay's temperature and found it to be elevated.  Megan pulled the blanket away from Fay.  "You can't use this anymore," she said, and set the temperature in the room to a cool 68F.

Alone in the room with Fay and Simon, they turned to me.

"We need to talk about the possibility of a c-section," Fay said, and Simon leaned in close to me.  It was like a team meeting at a football game.  "What if they come in and offer me a c-section?  I think I should take it."

I did not reply, but listened.

"It has been a long time and I don't know if this will happen naturally.  We have been trying everything."

"We can try a few more things.  Let's see what happens," I said.  Fay and Simon nodded, and we all relaxed into the possibility.


At midnight, Fay was complete.  Megan checked with Fay's pushes: "Pushing doesn't seem to move the baby," she said.  "We'll let you labor down, meaning the baby will come down on her own."  We pushed in many different positions, despite being connected to so many machines: squatting, side-lying, legs up, legs down, back, all fours.  As Megan's hand disappeared under the sheet, she looked at me and shook her head sadly.

I was drinking a lot of soda by this point.  It was past midnight and I was tired, walking down the long hallway to the staff kitchen for more caffeine.  I ran into Megan in the hall.  She whispered to me:

"I don't know," she said, "if this baby will be coming vaginally.  Her pelvis is so small.  I can barely get my fingers inside.  I can feel the head and it's just sitting there," she made a motion with her fingers, "just sitting there on the pelvic bone."  She looked at me with sad eyes.  "Talk to them," she said, "get them ready for a conversation about a c-section."  I nodded.

Going back to the room, I did not talk to them about the possibility of a c-section, because we were already on the same page.

Five minutes later, I saw Megan rushing in from down the hall.  The machine was beeping with the baby's decelerating heart rate.  She urged Fay not to push, and we went back to the breathing we had been doing earlier.  Megan turned off the Pitocin.

"Talk to us," I said to Megan after the contraction had passed.

She looked at Fay, then at Simon.  "The baby is not moving down," she said.  "I slide my finger up by the baby's cheek," she said, showing with her fingers, "and I expect the baby to slide against my finger with each contraction.  And the baby just isn't moving down."

We sighed.

"I don't know if this baby wants to come vaginally.  I think this may have to be a surgical birth.  You have tried everything you could: I have never seen a mom spend so much time upright and out of bed.  You really have tried everything, and I have tried everything that I could think of as well."

When she left the room, I talked Fay and Simon through the procedure.  I tried to explain what Fay would feel, when she could see the baby, and where Simon would be.  Where I would be.  This hospital had a strict one-person-per-patient policy, so I could not come into the OR as I had previously done in other births.

"Will you visit us tomorrow?" Fay asked.

"I will visit you in the recovery room," I said, smiling.  "I will see you as soon as I can. I will help you breastfeed your baby."  Simon was quiet, pulling on his hospital robe and paper shower cap.  We were all so exhausted.  Simon was worried both about his baby, who was showing signs of stress in utero, and about his wife, who had been in labor for 29 hours.

I knew Fay and I had done everything we could think of to turn and move the baby.  Simon was an amazing birth partner, pressing on Fay's back with almost every contraction for over a day.  Bags under our eyes and our feet heavy with the weight of relief, we collected our items, for we would not be returning to the delivery room.

As we rolled away, Megan exclaimed, "It's a party! A birthday party!"


That's the end of the story, at least, the story as I know it.  Baby Violet was born beautifully just after 2am, and though her head came out screaming before the rest of her body was even born, and though she had spent quite some time in a meconium-rich environment (for she had pooped quite some time ago), she had not breathed any of it in.  She had a ridge crosswise on her head, rather than lengthwise where the plates of her head typically fold over each other.  She was trying to get out, but really was stuck.

Latching on to the breast in record time, Violet was perhaps the most relieved of all to be born.


Was it premonition, or did she just know, when Dr. Kim had pressed her point, with a sly smile: "Just keep your mind open for a c-section?"  Had she known that a surgical birth was necessary, she still had the kindness (to Violet and Fay) to let labor go on naturally for as long as she did.

Megan, the second nurse, on whose shift Violet was born, approached the topic of a c-section with such kindness and sensitivity to the laboring mom that I was swept off my feet.  I appreciated her acknowledgement of our hard work, of the hours we poured into the labor, and the multitude of things we tried.  I liked how she looked Fay in the eyes when she said these things with a soft voice and maternal touch on her thigh.

And, for the doulas and birth partners that read this blog: What would you have done?

Tuesday, September 6, 2011

Birth partners: Lend me your ears!

I am actively seeking birth partners in California for interviews!  My research is on how birth partners prepare for birth and their roles, goals, and support strategies in supporting a mom through birth.  Sorry, doulas -- though I value your work, I am interested in the non-professional kind of birth partner.

Interviews last 30-45 minutes and are compensated with a $10 gift card to Amazon.

A birth partner is someone who was, or expects to be, in a role of emotional, physical, and/or informational support for a woman in labor.

You are eligible if:

  • You are expecting to be a birth partner in the next 3 months (i.e., the mom is in her 3rd trimester, or 26 weeks along); or you have been a birth partner less than 4 months ago.
  • The birth takes place (or plans to take place) in California.
  • You have never had a baby yourself.
  • You can dedicate 30-45 minutes of time.
Please contact me directly (phdoula <> gmail dot com)  or post a comment below.  Thanks!

Friday, September 2, 2011

Violet's birth. Part 1: Fay's negotiations.

Was it premonition, or just a standard interview, when Fay's obstetrician laid down the ground rules for laboring under her care?  Fay, Simon, and I stood in the doctor's office, surrounding the small woman with her hair in a messy pony tail, backing her against the wall.  Dr. Kim invited us there to talk about the birth plan, but instead of planning together, the interview was more of a lecture.  Point by point, she informed Fay and Simon of her procedures: what she would and would not allow.  Silently alarmed, I considered, point by point, the boundaries and tried to make sense of them.  Fay and Simon listened to Dr. Kim, nodding; I interjected clarifying questions and mentally noted the answers, knowing that a long discussion would come from this interview.  The boundaries were alarming because they would push Fay and Simon into a path of intervention after intervention, disregarding the body's natural tendencies to progress at its own rate in labor, and wholly undermining the ability of the body to give birth on its own.   Once, after I had interjected a question about her feeling about the birth party staying home after Fay's water had broken, Dr. Kim threw her arms up and exclaimed:

"If you want a midwife and a home birth, feel free to go hire one! I am a physician, and these are my rules."

I asked no more questions.

After meeting twice more with Fay and Simon before their next prenatal appointment a week later, and knowing there no time to lose, I made a list of the items Dr. Kim mentioned along with the things Fay and Simon should push for in their discussions with Dr. Kim.  Thus, negotiations began, and, armed with the marked-up list, Fay went to Dr. Kim's office the following week.


We had studied a list of ways to reduce the risk of having a c-section, and took some inspiration from it.  Here is the list that Fay used to discuss her birth plan with Dr. Kim, after Dr. Kim had specified her version of a birth plan.
  • Bad idea: Dr. Kim would let Fay go until 41 weeks, and then induce.
    Better idea: Wait until 42 weeks to talk about induction.
    Reason: When labor starts is hard to predict.  The average gestation is 40 weeks, with anything between 38 and 42 considered normal.  The baby and the body know best.  Estimated due dates are just that: estimates!
  • Bad idea: If water breaks before contractions start, labor induction with Pitocin follows after 2 to 3 hours.
    Better idea: If the fluid is clear and has no odor, wait.  Wait 24 hours.  If nothing, try natural methods.  Try natural methods while waiting.
    Reason: Contractions will usually start on their own within 24 hours.  If you are impatient, or nothing is happening, first, try to induce naturally.  Two to three hours is not long enough.
  • Bad idea: Come to the hospital when contractions are 6 to 7 minutes apart.
    Better idea: Come to the hospital when contractions are 4 minutes apart, lasting about a minute, and this pattern has gone on for an hour or more.
    Reason: When contractions are 6 to 7 minutes apart, you are in early labor.  Getting to the hospital early can increase your chance of interventions leading to a c-section.  Early labor can last a long time, so it is best to be at home, where you are more comfortable and can rest and eat.
  • Bad idea: Continuous monitoring with telemetry (wireless) unit upon entering the hospital.
    Better idea: If mom is laboring naturally, monitor the baby intermittently with a doppler unit.
    Reason: Continuous fetal monitoring is associated with an increase in c-section rates.  Sometimes there are things on the "strip" (monitor readout) that can be misinterpreted as fetal distress and a c-section can be called when no danger is imminent.  This is less likely to occur with intermittent monitoring.  Also, with intermittent monitoring, the nurse has to physically come in and look at you when she monitors, rather than watching your strip from the nurse's station.
  • Bad idea: Progression expected is 1cm an hour; failing that, augmentation with Pitocin.
    Better idea: There is no such thing as "expected progression."  Do not put time pressures on a mom in labor.
    Reason: Would you tell people how much food they need to eat per minute?  And if they do not meet that expectation, would you threaten to force-feed them?  Every person and every labor progresses differently, and labor progress is affected by many different factors (including physical and, yes, emotional ones).  Putting a laboring mom on a time schedule only makes her nervous; it does not actually speed things up.  Things that do speed up labor include continuous support (e.g., from a doula), being allowed to move around (especially upright positions) and giving her the space and freedom to express herself.
  • Bad idea: No eating upon entering the hospital.  But drinking is OK, even with an epidural.
    Better idea: Do not explicitly restrict food or fluid intake.
    Reason: Labor is hard work, and if mom is hungry, she should eat.  I have already ranted about the importance of a sip of water after every contraction, so I am glad to hear that even with an epidural, drinking is allowed.  Most moms will not be hungry past a certain point in labor because the digestion slows way down, but occasionally (especially with a long labor) mom will need some energy.
  • Bad idea: Baby will be taken away after birth for cleaning unless parents expressly request to breastfeed.
    Better idea: Baby will be placed directly on mom's chest after birth, and left there for bonding for at least an hour.
    Reason: Smelling the baby.  Feeling the baby.  Wiping the baby.  Bonding.  Breastfeeding.  Oh, and the  International MotherBaby Childbirth Initiative.
It took more than one visit to clear up the questions and concerns that Fay, Simon, and I shared.  Over the next several weeks, Fay whittled down at Dr. Kim's stringent guidelines, point by point, and Dr. Kim eventually agreed to everything on Fay's list, saying sweetly that she can see what Fay wants from her birth and she will accommodate her (though not mentioning how).  

Over these weeks, outwardly, we were patient with her, and she was patient with Fay.  But secretly I had started thinking about how one transfers care after 36 weeks -- what is the process involved, and who would take on someone else's patient.  Whenever Fay or Simon asked her what Dr. Kim would do to help them labor normally, Dr. Kim would don a sweet smile, place her hands on the wall behind her, and say, "Just keep your mind open for a c-section."  I was shocked.  Fay and Simon were confused, and felt unsupported.  I began to feel that we would need to be subversive to get the kind of birth Fay wanted: "forget" to call in early labor, come in "oops-late," and refuse non-emergency procedures.  I did not like this train of thought.  It is better when the parents, doctor, and doula are all on the same page and have the same goals in mind.

In the end, the result of the series of interviews was positive, and all of our concerns were addressed with a good-natured smile: "If the mother and baby are doing well," Dr. Kim said, nodding, on all points, "that is fine."

Dr. Kim agreed to wait until 42 weeks gestation, given that she monitors the baby with ultrasound to check for fluid level and non-stress-tests (NSTs) every few days after 41 weeks; she agreed to trying all natural methods before any chemical ones; she agreed to let Fay labor at home as much as she liked, even saying she could come to the hospital for just the birth.


The pregnancy progressed uneventfully.  The due date came and went.  Forty weeks.  Forty-one weeks.  Fay had passed her NSTs with flying colors, but the fluid level around the baby was shrinking.   This is normal.  It does that.  But she was late, like an overdue library book, and now it was time to start talking about induction again.

I did not attend this discussion, but I know that Fay's attitude had changed.  Going from wanting labor to start on its own and under no circumstances using Pitocin to induce or augment labor, after the visit with Dr. Kim, Fay said she wanted to induce on the first day of week 42 rather than waiting until after the weekend.  I asked why.

"I think I have lost faith in my body's ability to go into labor naturally."

After initially trying a pep talk, I sighed.  Not because of Fay's comment.  But because I sincerely felt that Dr. Kim had finally gotten to her.  Of course, it was Fay's decision, and I would be by her side no matter what.

Fay set up her induction appointment for the night before the 42nd week.  Following my advice, she again brought a list of questions with her to ask Dr. Kim.  Here is the list, along with Dr. Kim's answers.
  • Can we wait a few more days?
    Reason: If the instruments Dr. Kim is using to measure the comfort of the baby (namely, the non-stress-test (NST) and the ultrasound to verify the fluid around the baby) show that the baby is doing well, can we wait?
    Answer: Though unhappy about the option, Dr. Kim said that yes, Faye and her baby can wait three more days, given a negative NST.  Then, Faye would be 42+2 (two days past 42 weeks) on the evening of the induction.
  • What is the exact procedure for induction?
    Reason: Knowing is half the battle.
    Answer: Cervidil at night, then we wait 8 to 12 hours (see below).  If Fay is not in active labor at the end of 12 hours, we start Pitocin, increasing the dose every 30 minutes.  Faye expressed concern.  "In 3 out of 4 cases," Dr. Kim said, "Cervidil alone does the trick," and Pitocin is not needed.
  • Can Cervidil be started in the evening before bed, with the night spent in the hospital?
    Reason: This gives the parents time to rest while letting the cervix ripen.
    Answer: Yes, it is started at night.
  • How long can we wait after Cervidil for contractions to start on their own?  Can we go home to wait?
    Reason: Once the cervix is ripe and thinned out, it may be just a matter of time for contractions to start on their own, or we can use natural methods with some success.
    Answer: "No, you cannot go home after Cervidil, because we need to monitor the baby," Dr. Kim said.  "After Cervidil, we wait 8 to 12 hours for dilation to be 4cm" -- that is, 12 hours to get into active labor after administering Cervidil.
  • If Pitocin is required, can we stop Pitocin after contractions have a strength and pattern that dilates the cervix (and resume trying to labor naturally)?
    Reason: Sometimes the body just needs a kick-start and can maintain a good labor pattern on its own.
    Answer: Yes.
  • Once induction is started, how long do we have to deliver?
    Reason: Induction means time pressure.
    Answer: Induction in the 37th week can take a long time (i.e., when the baby and mom are not ready to deliver).  But in the 42nd week, Dr. Kim said the induction should not take long: she expects the delivery to happen within 12 to 24 hours, and said she would be willing to wait three days (the same three days to 42+2).
Everything seemed fine.  Dr. Kim agreed to let the couple come in for a NST on the morning of the start of week 42, and then induce on the evening of 42+2.


And then, Dr. Kim added, offhand:

"And if that does not work, we can try Cytotec."  Cytotec is a pill inserted vaginally (and kept there to dissolve) in half-pill doses and it is sometimes used to ripen the cervix.

Fay and Simon rushed home to research this and were shocked -- shocked! -- that their kind (now, with some massaging) obstetrician suggested it.  Cytotec (misoprostol) has not been approved for use as a labor inducer by the FDA (though it has been used as such off-label for years), but also it is bad news: it is associated with uterine rupture (when the muscle of the uterus breaks) and fetal tachycardia (when the baby's heartbeat is too fast).

So when Fay and Simon learned about this, they felt betrayed.  They cried, "How could Dr. Kim suggest such a thing?"  Fay read more about it and was convinced that she would not let Cytotec anywhere near her cervix.  And her feelings about fighting for a natural birth were reawakened.

Continue on to Part 2 of Violet's birth, in which Fay has a baby girl.
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