PhDoula

Choosing a birth facility in five easy steps

2012-02-13T14:27:00.000-08:00

How do you choose where to give birth? This post attempts to answer the question of how to choose where to give birth -- where to look for data, and what questions to ask yourself.

In the region of the US where I practice, for low-risk pregnancies, there are basically two options: birth at home with a midwife, and birth in a hospital with whoever happens to be on call (sometimes this is your own doctor or midwife).

Birth at home

Choosing a safe homebirth requires forethought. I am not an advocate for unassisted birth, with no medical professional on hand to help. I think that choosing a homebirth is a big deal and requires sufficient preparation. Selecting a homebirth midwife is a lot like selecting a doula, except there is more responsibility involved in a midwife. (And, you should have a doula as well.) Here are some things to ask your midwife when you consider birth at home.

How long do you spend in prenatal visits with me? Midwives are known to spend longer in each prenatal visit with their clients than obstetricians or doctors.
How do I prepare and educate myself for birth? Some midwives teach their own homebirth childbirth preparation classes.
When I am in labor, when will you come to my house? How long will you spend with me in labor? Midwives vary widely on when they will arrive. Some will arrive in active labor and will provide doula-like support throughout the birth. Most will arrive at the end of active labor, in time for pushing, to help you have the baby.
How many assistants do you have, and will they be coming to help with the labor? Some midwives send their assistant(s) first for support, and will come later. Others come with their assistants. There should be at least two trained midwives with you: one for you, and one for the baby.
What kind of equipment do you provide? Some midwives will bring a birth (yoga) ball and/or birth stool, and may rent a tub for you to labor in.
What kind of emergency equipment do you have in your midwifery kit, and under what circumstances do you use it? This should be standard, but should include oxygen, Pitocin, sutures, etc. The oxygen can be administered to the mother or the baby; Pitocin helps with postpartum bleeding; and sutures are used to sew up any lacerations (tears) in the mother.
What are the factors that will cause a transfer to the hospital in labor? This is fairly standard as well. Expect answers such as labor before 36 weeks gestation (preterm baby), induced labor (ask when induction will occur), meconium in the amniotic fluid at any point in labor, baby's heart rate decelerating (measured with intermittent monitoring), bag of waters being open for over a certain amount of time (24 hours, 36 hours), and maternal fever, to name a few. Some midwives will not deliver breech babies and multiples (twins, triplets).
How long will you stay with me postpartum, and how often will you check on me and the baby? Expect that the midwife will stay at least a couple hours postpartum, until you are settled with the baby, and will check on you frequently in the following days.

Of course, you can also ask about transfer rates (the percentage of mothers that transfer to the hospital), c-section rates, emergency intervention rates, and so on, but that may not give you a good idea of what the midwife brings to the birth. These numbers could tell you her willingness to relinquish control, or to "allow" interventions to happen to the mother, but there is a chance that all it tells you is whether she has had a run of good luck or a run of bad luck.

Research what other mothers said about their home birth. Check out The Birth Survey project, which is a self-reporting tool in which mothers can enter their own experiences and information in the months after their birth. Keep in mind that these data may be skewed because of selection bias: this is not a randomized study, and mothers choose whether or not to participate.

Finally, skip to Step 5: You are not locked in. Though it may be trickier to switch home birth providers later in pregnancy, it can be done.

Birth in a hospital

Choosing a hospital can be a hairy task. No two hospitals are alike. I hope this guide will help you narrow down your choices.

Step 1: Choose a non-profit hospital.

Nathaneal Johnson of California Watch (2010) reported that for-profit hospitals have a higher c-section rate than non-profit hospitals. And that increase in c-section rates is nontrivial: mothers giving birth at a for-profit hospital have a 17% higher chance of delivering surgically. For-profit hospitals are more likely to perform costly procedures, less likely to serve under-served populations, and less likely to have breastfeeding success.

Step 2: Figure out what's important.

Priorities the importance of the following things: cost of birth, mode of delivery (vaginal vs c-section), c-section rate, breastfeeding success, diversity of population served, infant outcomes, whether you will have a room mate, what language(s) are spoken, where your doctor/midwife practices, how many residents (trainees) there are, how close the facility is to where you will spend most of your labor, and any other factors you consider important to you.

Step 3: Do the research.

There are several ways to look at birth facts. Check out Health Grades and search for the hospitals in your area. In California, you can use California Watch to look at statistics. For example, say I wanted to compare San Francisco General Hospital (SFGH) and UCSF Medical Center (UCSF) -- both non-profit teaching hospitals in the center of San Francisco, California.

Figure 1 shows the California Watch page for SFGH. Interesting things to note here: the decreasing trend of the low-risk c-section rate across three years, and the most recent reported average is 11.10% in 2007, much lower than the US average of 33%. This is very reassuring if mode of delivery is important to you and/or you wish to avoid a c-section. The Hospital Info section below tells you that SFGH is a non-profit teaching hospital that caters to under-served families, with over 60% of the patients coming from a low-income household. If breastfeeding is important, the 88.90% exclusive breastfeeding rate is a very good sign, and there is a positive correlation between beginning breastfeeding in the hospital before discharge and continuing to breastfeed for at least a few months postpartum. Finally, the (risk-adjusted) VBAC (vaginal birth after c-section) rate is a promising 30.23%.

Figure 1: Decreasing c-section rate for
San Francisco General Hospital (California Watch)
Click to enlarge

Figure 2 shows the California Watch page for UCSF. You will notice that it is very similar to SFGH: relatively low c-section rate of 14.20% in 2007 (compared to the US average of 33%), even when you look at the base c-section rate: 19.47% of all mothers, even high-risk mothers, deliver surgically. About 30% of the patients are low-income, judging by the insurance carrier. The breastfeeding success rate is 74.77%, which is still very good -- three quarters of all babies born at UCSF are exclusively breastfed when they check out. The risk-adjusted VBAC rate is 24.23%, which is fairly good.

Figure 2: Information on the University of California - San Francisco
Medical Center (California Watch)
Click to enlarge

Another thing these charts do not tell you include whether or not vaginal breech birth is attempted at each hospital (it is).

Health Grades gives both of these hospitals one star for maternity (worst grade possible), but it is unclear why. So let's take a look. Figure 3 shows that San Francisco General Hospital (SFGH) and UCSF Medical Center (UCSF) each has one star. SFGH reports 64% of the cases that UCSF received in 2011 -- implying that SFGH is a smaller hospital. But here is where it gets interesting.

At SFGH, 2544 women delivered vaginally (79.62% of all women that delivered at SFGH in 2011), 12.23% (N=311) had complications related to the vaginal delivery. But the national average for complications is 8.21% so we would expect only 209 women to have had complications. So more women have complications at SFGH due to vaginal delivery than the US average.

We know that SFGH had a 11.10% c-section rate (in 2007) from Figure 1 and we will assume the same c-section rate in 2011. In Figure 3, we see that there is a 20.28% c-section complication rate. That is, of the 651 women that delivered by c-section at SFGH, 20.28% of them (N=132) had complications related to the surgery (e.g., infection, excessive bleeding, etc.). But, the national average is 4.34% so we would have expected only 29 women to have had complications. So, the c-section complication rate at SFGH is more than four times the US average.

At UCSF, 3745 women delivered vaginally (74.81%). Of these, 15.09% had complications (N=565). The national average for complications related to vaginal delivery is 8.21%, so we would have expected only 308 women to have complications. The vaginal delivery complication rate at UCSF is almost twice the US average.

Now, UCSF's c-section complication rate is a little worse than SFGH's, at 13.16%. That is, of the 1261 women that had c-sections, 13.16% of them (N=166) had complications. Since the national average is 4.34%, we would have expected 55 women to have had complications. The c-section complication rate at UCSF is three times the US average.

Health Grades does not explain the "Newborn Survival" column so we have to take it at face value, and, if possible, compare the newborn survival (text) across the hospitals we wish to examine.

Figure 3: One-star ratings in maternity care for San Francisco General Hospital
and UCSF Medical Center (Health Grades)
Click to enlarge

If we wish to investigate whether there is a difference between any of the following, we can run a quick Chi-square on the data from Figure 3.

SFGH and the national average, in terms of vaginal and c-section complications
UCSF and the national average, in terms of vaginal and c-section complications
SFGH and the UCSF, in terms of vaginal and c-section complications

We find that indeed, there is a difference in all of these categories. Although calculating Chi-square does not give us the direction of the relationship, we can see that SFGH and UCSF both fare poorer than the national average, and that c-section births at UCSF are more than twice as likely as expected to have associated complications. Yikes! Figure 4 contains all of these calculations.

Figure 4: All correlations for SFGH, UCSF, and the national average.

Research what other mothers said about their birth experience at the facility you choose. Check out The Birth Survey project, which is a self-reporting tool in which mothers can enter their own experiences and information in the months after their birth. Keep in mind that these data may be skewed because of selection bias. For example, SFGH has 60% under-served population; are mothers from this group more or less likely to fill out an online survey than higher-income mothers, in the interests of science?

Ask your friends about their experiences in the facilities. One gal I know praised her birth facility for its harp music and tea time in tones that I understood to be insincere. Then she divulged that she had a room mate, and she hated the experience of someone else's baby crying in the night next to her own bed. No amount of tea could make that memory go away.

Step 4: Visit.

Knowing, on paper, that these hospitals are so similar, how can you choose the right one for you? Visit. Maybe it is a prenatal appointment with a midwife or obstetrician. Maybe it is a procedure, like lab work or the 20-week ultrasound. Maybe it is a maternity center tour. Get a feel for the dynamics of the hospital, for the nursing staff, and for the check-in and check-out procedure. Imagine arriving in labor at rush hour. Is it crazy, with papers flying and nurses pulling their hair out? Or is it a smooth and calm atmosphere? If it is a teaching hospital, ask when the new residents start their training. If their first week corresponds to your due date, and that makes you nervous, that could be a strike in the "no" column. If you are taking a tour, look around the birth room and ask what kinds of things the nurses usually try to help a mother labor. Look for answers that promote relaxation (e.g., birth ball, music player), movement (e.g., waterproof wireless fetal monitors), and hydrotherapy (e.g., bath tub, shower). Ask about routine procedures and if any of them can be skipped (e.g., pubic shaving, IV, Pitocin for labor augmentation).

Step 5: You are not locked in.

Even if you have made your choice of birth facility, or obstetrician, or midwife, or doctor -- whatever -- you are not married to that choice. You can always, always switch. Remember that you are paying good money for the services that will be rendered to you. You are hiring a medical professional. If you are unhappy with your choice, and you are unable to reconcile it (by talking about it, e.g.), you can switch. I have asked doulas, midwives, and nurses in the past: When is it too late to switch providers? The answer: After the baby has come.

Good luck, and happy birthing!

HypnoBirthing for Birth Professionals: A seminar

2012-02-07T14:52:00.000-08:00

Last weekend, I attended a seminar called Supporting the HypnoBirthing Mother and her Partner: A Workshop for Birth Professionals. You may know me as a scientist. As a researcher. As a critically-thinking repository of information. You probably do not know me as a HypnoBirther. Which I am totally not.

But this workshop left me with several ideas of how to use aspects of the method to help a mom and her partner feel calm and confident. These are using slow, deep breathing with some position change, and using positions in which the weight of the body is being held. Having confidence in visualization suggestions is also key in creating an atmosphere in which the body can relax.

But perhaps the biggest benefit of HypnoBirthing is that it gives the mother and her partner something to do throughout her entire labor.

What is HypnoBirthing?

HypnoBirthing, also called the Mongan Method (after its creator, Marie Mongan) uses hypnosis to enhance the trance-like altered state of active labor. That is my definition. Maybe yours is different.
In effect, HypnoBirthing is relaxation, breathing, and visualization.

Figure 1: Fear-tension-pain cycle, as per G. Dick-Read.

The crux of many popular modern childbirth philosophies is the "fear-tension-pain" phenomenon. When you are afraid or anxious, you tense up. When you tense up, you feel more pain. And when you feel more pain, it is scary. So if you can teach your body to relax, you can nip the cycle in the bud and things will hurt less. At the risk of using Comic Sans, I have illustrated the cycle on the right in Figure 1.

The idea is that the mother and her partner begin preparing for a hypno-birth early -- around the 20th week of pregnancy, much earlier than the typical childbirth education which is usually around 35 weeks -- and the preparation includes childbirth education (that is the Birthing part) and guided meditation (that is the Hypno part) which is to be practiced at home in the months to come. The focus of the meditation is deep relaxation, the kind you get when you can no longer tell where you are or how long it has been, with a particular emphasis on breathing and visualizing the baby. And when the time comes to birth the baby, the mother has practiced relaxation so much that she can enter that state of deep relaxation easily and willingly. Add in some breathing and visualization techniques, and you have it.

What are these doctors doing here?

The instructor of this seminar for birth professionals, Rachel Yellin, a spunky gal with a huge mane of curly hair draping her cheeks, shoulders, and back, addressed the roomful of birth professionals. There were seventeen women and one man (a man!) in the room. Most were birth doulas, some were also yoga instructors and massage therapists. There were two obstetricians (the man was one) and a midwife; two grandmothers or soon-to-be grandmothers; and a few volunteers from the doula organization to which I belong. And there was me, researcher, marked by academic articles seeming to fall out of my ears.

I was as surprised (pleasantly) as Rachel to see obstetricians in the audience. It was surprising because douas are taught that obstetricians only come to deliver the baby. They do not participate in labor support. So what were these three clinicians (two OBs and a midwife) doing in the audience? It turned out that Jack was going to be supporting his brother and sister-in-law in the coming months, in the birth of their child, and he was terrified: having never been in a position of support, especially in early labor, and especially continuous, he was lost. As a birth professional, he did not want to take a full-blown childbirth education class, so he came here instead. Blair, the other obstetrician, and Alice, the midwife, wanted to learn how to help their hospital staff support HypnoBirthing couples. Learning more about the process of HypnoBirthing would help them not startle anybody and break the focused flow the mother had established for herself.

They really stole the show. Doulas had so many questions -- about obstetric interventions, procedures at their hospital, and, most importantly, how doulas can help. I touched on this a bit in a previous blog post, Why I'll Never Be a Nurse: some newer doulas have just enough education to be a nuisance, but not enough to be an asset to a birth team. I watched the collaboration unfold, and in the fifteen short minutes that the conversations proceeded I saw the doulas' eyes light up, and some were taking notes. There really does need to be more training for doulas about hospital procedures, regulations, and liabilities. But I digress.

Do you want me to help you?

This is the first question any support person should ask any supportee. Do you want me to help you? Sometimes the answer is no. Sometimes the mother may want to feel miserable for a while, or to complain, or to find her own way. In that case, be present and wait.

But if the answer is yes, the support person will have some work to do.

HypnoBirthing is not a comfort measure. At least, not in the common sense of the words -- which HypnoBirthers are encouraged not to use. The connotation of "comfort measures" is that something you can do will make the mother more comfortable. The idea is not to get more comfortable, but to dive deeper into the sensations. The idea is to relax more, enter a state of deeper relaxation: one that will allow the mother to open herself to the point of letting the sensations of labor sweep over her body.

Labor as an altered state of consciousness

Especially starting with active labor, when the mother can no longer ignore her body, and must concentrate her energy inwardly, the mother enters an altered state of consciousness. HypnoBirthing tries to harness this potential and works with it to help the mother enter this state of consciousness sooner and deeper than otherwise. The mother's focus turns inward and she uses the techniques outlined above and below. Because the mother is in an altered state of consciousness, she is susceptible to suggestion. The altered state of consciousness can be considered meditation, and here is thus dubbed hypnosis. And because in this altered state, the mother is more keenly aware of suggestions, we call this altered state suggestion hypnosis. It is a relaxed altered state of consciousness.

Rachel said, "Remember that anything and everything that happens around a woman or to a woman during labor is a suggestion." You look at the clock? Suggestion (too slow). You look at the read-out from the monitor? Suggestion (what's wrong). The nurse does a vaginal exam? Suggestion (things go in, not out).

She said as labor support persons, we must be mindful of everything we do and the suggestions we give off, even unintentionally.

I could not agree more.

Three reasons for purposeful breathing

Rachel explained that there were three main reasons for purposeful breathing in labor, which is breathing while really concentrating on the breath going in and out of the body.

Oxygen. That is, you need it to survive. And so does the baby. Bringing oxygen to all the parts of the body that are doing the Big Work of Birthin' is the main reason.
Sound. When the mother is concentrating on the sound the breath makes as it passes her throat and her nose (like yoga breathing), she cannot possibly concentrate on anything else. She cannot talk and (especially) complain, and she is forced to relax. It helps her enter and maintain that altered state HypnoBirthing is known for.
Bridge from Mother to Baby. Visualizing the baby and its uterine cocoon helps the mother's body go through the steps of birthing a baby. And a continuous flow of oxygen to the baby is very important for the baby's and the mother's wellbeing in labor.

The good, the bad, and the skeptical

For me, there are two sides to every coin. Here are a few of those coins that hit a bell for me.

Relaxation in labor
The idea: Relaxing in labor helps labor move faster and hurt less.
The good: Certainly key! How many mothers exhaust themselves in early labor, pacing or cleaning? Rachel explained the importance of relaxation and breathing. She said to imagine a mother in labor as she is climbing up and down stairs or pacing the hallway to get things "moving," as mothers in early labor are apt to be encouraged.

Figure 2: Slumped forward over baby

"Pain in labor comes from the baby pressing against a dehydrated uterus," she said, meaning that the uterus lacks oxygenated blood. "Where is the oxygen? It is in the thighs, as she mounts each step; in the heart, beating faster, in the arms, holding on to the handrail." Consider how much more blood her uterus would be getting if she were sitting, slumped over her baby (Figure 2); or lying on her side, curled around her baby; or on all fours, letting the weight of her body be held by a yoga ball. As an aside, I could not find a single freehand drawing program on my entire hard drive -- my apologies to the woman pictured in Figure 2.

"The idea is," said Rachel, "that all this movement and letting gravity help will bring on stronger and harder surges." Oh, I forgot to mention. Contractions were renamed as surges because you want to give the idea that things are loosening, not tightening. Surges. Say it with me, and have some granola. It is good for you. "The harder surges may not be doing anything for the mother besides exhausting her." Rachel's implication was that the active mother's uterus depleted of oxygen is the reason her surges are getting more intense, not that labor is actually moving faster.

Thus, the HypnoBirthing method relies on supported-body positions that do not require much exertion by the mother for two reasons:

Oxygen getting to the uterus, and
Mother staying very relaxed.

The skeptical: None, really, but I wanted to mention one thing: The supported-body positions must be changed on a regular basis. Because in the end, we do rely a little on gravity, and we need to help the baby traverse the narrow passage. As an active participant, the baby needs to tuck and turn and twist, and changing position frequently helps baby do just that.

Three types of breathing

The idea: Practicing three types of breathing (sleep, balloon, and birth breathing) helps the birth process.

Sleep breathing is a medium-length inhale and long, slow exhales lasting twice as long as the inhale: count in, in, in; and out six times.
Balloon breathing is similar to yoga breathing, using the sound in the back of the throat as a focal point in the meditation. Think about saying "haaaa" so that the whole room can hear you. Now do it with your mouth closed.
Birth breathing, or "breathing the baby down," is a sequence of short, light grunts with which you expand the size of the stomach. They are like stomach thrusts using the air in your belly. This breath is supposed to be used in the second stage of labor.

The good: Sleep breathing promotes oxygen exchange through the body. Way to oxygenate that uterus, girl! Balloon breathing helps focus! And birth breathing helps the baby move into position gradually, come down the birth canal slowly, and be born gently with little danger to the perineum and little stress to the baby.

The skeptical: A few comments.

Early iterations of the Lamaze method tried to teach breathing. Remember the "hee-hee, ha-ha" breaths that movies always implement? That is Lamaze from the 70s. Researchers found that not only does Lamaze breathing not work as a labor support tool, but also the mother hyperventilates with these quick breaths. Good thing they got rid of that, right?
No animal has birthing breathing rituals in the wild. Have you ever seen a dog giving birth to puppies while yoga breathing?
When Rachel got to birth breathing and how it is meant to be performed in the second stage of labor (i.e., pushing), showing us how to do it, with her stomach bouncing rhythmically, we (that is, the class) imagined a woman in labor doing this and roared with laughter. "I have never seen a woman do this," Alice (the midwife) said, "and I have seen a lot of HypnoBirthers." When the body bears down, there will be no such breathing.

Remove the reference to pain
The idea: If you reframe the sensations a mother experiences, she will not be tempted to see it as pain. "Pain is when your body says something is wrong," Rachel explained. "When you are in labor, there is nothing wrong. The sensations you are having are perfectly normal. They can be uncomfortable, sharp, stabbing, tightening, tingling -- whatever!" She said that if you cut your finger, that hurts, and that is painful. Your body sends the signal to your brain so you can fix it. But in labor, there is nothing to fix.

The good: The woman in active labor is already in a deep state of relaxation, and an altered state of consciousness, so asking about pain and entertaining conversations about hurting are all very suggestive to her. Perhaps because pain is scary, and fear leads to tension, and so on. Refraining from bringing a mother's attention to pain is probably a very good idea.

The skeptical: Alice, the midwife at the session, said she frequently sees HypnoBirthing patients come in and she cannot tell, at all, how far along in their labor they are because they are relaxed and smiling. She says it can be a real challenge, because they are the same patients that try to forego vaginal exams to determine labor progress. Rachel agreed and said the only way she can tell if a HypnoBirthing mom is pushing is she sees her stomach contract rhythmically.

So perhaps a strong benefit of HypnoBirthing is that nobody sees you in pain. When the mother is in a state of deep relaxation, nobody can tell how much discomfort she is feeling. That includes her care staff and her partner. If her partner is more relaxed (i.e., not worried about the sensations she is feeling), he or she can provide better care for her. Anxiety related to the mother's pain level is a major fear factor for birth partners.

When HypnoBirthing women recall their experience, they do say things like "Oh, it hurt like hell," or, as Rachel retold, "It felt like being stabbed by a fire poker." So clearly, simply not thinking about pain does not make the pain go away. But it does alter other peoples' impressions of the mother's sensations because outwardly, she is not complaining.

The Benefits of Relaxation

A pamphlet about assisting women in labor using the HypnoBirthing techniques [doc] published in 2010 by Brandy Astwood, a HypnoBirthing childbirth educator, outlines the relevant research supporting HypnoBirthing and provides helpful suggestions for birth partners and nurses on how to help a woman that is using deep relaxation as her primary labor strategy. Her pamphlet collects results from several sources and is repeated here.

Fear, stress and tension have long been known to be associated with increased levels of pain as reported by patients. Grantly Dick-Read, MD, described the “Fear-Tension-Pain Syndrome” in the 1920s, and since that time obstetrical care providers have noted that education and stress management strategies have been effective in decreasing the level of pain reported by women in labor.

Hypnosis has been used effectively in the management of pain for over a century, but fell out of favor with the advent of safer, more effective analgesia/anesthesia. Over the years, several studies have been undertaken to research the efficacy of hypnosis in childbirth. A meta-analysis of these studies, “Hypnosis for Pain Relief in Labour and Childbirth: A Systematic Review,” appeared in the British Journal of Anesthesia in 2004. The article states
This report represents the most comprehensive review of the literature to date on the use of hypnosis for analgesia during childbirth. The meta-analysis shows that hypnosis reduces analgesia requirements in labour. Apart from the analgesia and anaesthetic effects possible in receptive subjects, there are three other possible reasons why analgesic consumption during childbirth might be reduced when using hypnosis. First, teaching self-hypnosis facilitates patient autonomy and a sense of control. Secondly, the majority of parturients are likely to be able to use hypnosis for relaxation, thus reducing apprehension that in turn may reduce analgesic requirements. Finally, the possible reduction in the need for pharmacological augmentation of labour when hypnosis is used for childbirth, may minimize the incidence of uterine hyperstimulation and the need for epidural analgesia.1
Obstetrical patients using self-hypnosis have been shown to have lower scores for pain associated with childbirth, shorter duration of both first and second stage labor, increased number of spontaneous births, decreased use of analgesia, anesthesia and labor augmentation and infants with higher average Apgar scores.

HypnoBirthing® teaches women to relax quickly and completely with uterine contractions, and to use visualization to help facilitate cervical effacement, dilation, and fetal descent. Women and their birthing companions are taught that fear and tension lead to increased levels of catecholamines, which ultimately causes increased pain during labor. The positive effects of visualization are thought to be similar to those achieved by athletes using mental imagery to prepare for competition. Rather than using multiple types of breathing and imagery to distract the laboring woman from her discomfort, HypnoBirthing® allows a woman to become deeply focused upon the birthing process.

When in labor, a woman using this method is not asleep or unconscious, and is receptive to suggestions made by her birthing companion and others. For this reason, references to pain, medications and procedures are best kept to a minimum. Women using HypnoBirthing® will ask for analgesia or anesthesia if they need it.

HypnoBirthing® encourages the laboring woman to allow passive descent in second stage and to “breathe the baby down” with release of air as she “feels the urge.” The HypnoBirthing method discourages Valsalva pushing, and beginning to push before the woman has the involuntary urge to do so. Recent studies have shown few risks and some benefits in allowing the mother to “labor down” in second stage, allowing passive descent, as opposed to “pushing” as soon as cervical dilation is complete. With passive descent, there are fewer fetal heart rate decelerations and less fetal acidosis. Maternal benefits include a shorter period of “pushing” and less fatigue. Unless specifically instructed otherwise, women begin bearing down spontaneously when the fetal presenting part is well down in the birth canal; they will generally wait until the contraction peaks and then give a series of “mini-pushes” with air release.

HypnoBirthing® stresses that the goal is a gentle and safe birth for the baby. Staying relaxed and focused upon her baby and the birthing process enables the birthing woman to remain calm and more comfortable. Her companion(s) will help her to maintain this calm focus with music, dim lights, soft touch, and speaking words of encouragement. They will also help her to remain well nourished and hydrated and assist her in moving about. The companions will advocate for the mother and baby if interventions are suggested and help the woman to make informed decisions.

We find that, no matter what turn the labor and birth may take, most couples are very satisfied with their birthing experience. Because they are calm and relaxed, they will feel empowered to make good decisions if interventions become advisable.

-- Brandy Astwood's pamphlet, 2010 [doc]

Sue's second baby

2012-01-22T14:53:00.000-08:00

Sue and I go way back -- in fact, the first birth I ever attended was the birth of her first baby. So when she was pregnant again, there was very little discussion about whether or not I would be at her birth. Even though I had moved two hours away from her house, it was just understood that I would be there, rain or shine, night or day.

And that is exactly how it was.

Past due part deux

Five days past her due date, Sue felt her first real labor contractions. She had had contractions for months, just like with her first baby, before real labor set in. Some contractions, like the Braxton-Hicks that plagued her throughout both pregnancies, did nothing, and others opened her cervix, a little at a time.

"Why doesn't my kid like to pee in nature?" Sue lamented one morning. "I have never heard of a toddler that doesn't want to use the great outdoors. I tucked him under my arm and wedged him above my huge belly and ran with him looking for a bathroom. Contractions the rest of the day."

Three days past her due date, her OB checked her cervix at her request. "She says I have a super thin and super favorable cervix and I will go into labor for reals next time I start contracting," Sue related. "She didn't give me a number for dilation but I could tell she could get her fingers further into my business."

Of course, I gave the best advice I could: "Are you thinking what I'm thinking?" I wrote on my antique cell phone. "That's right. Mad nookie all afternoon, and baby this evening." Of course, I was not even a little bit kidding. Sex is a great way to stimulate contractions for two reasons: orgasm has been known to set off contractions (because orgasm is a type of contraction); and semen contains the same chemicals as the stuff they use to induce labor, so just letting it hang out in the vagina will help ripen the cervix. Plus all those orgasmic hormones are the same ones that course through a mom's body when she is birthing a kid and breastfeeding. Sue replied that the timing would not work out -- it would complicate the pick-up from day care for her toddler, so she decided to wait.

But she did not have to wait long: just two days later, it happened. The familiar tightening of the belly, rhythmic, every few minutes. Just like last time! That evening, Sue made dinner for the last time for her family of three. Her toddler helped her put the finishing touches on the pie, and they waited together for it to bake. I stopped by for a while, took a look around, and read a book with the toddler. Sue said, "You can probably just go home. It will be just like last time. You know, days of early labor. I'll call you if anything happens."

I went home, and straight to bed at the early hour of 9:30pm, snuggled up with my own toddler, who was about seven months older than Sue's.

It's code for "get me some caffeine."

No calls all night. At around 8, as my kid and I were getting up, I got a message from Joe. They were at the birth center (more like a maternity hospital, because they have anaesthesiologists on site, and a surgical room) checking on the labor because the contractions went on all night. Sue slept for two minutes at a time all night long. And on that note, I was on my way -- despite Joe's warning: "We may be sent home again." To explain -- the birth center generally practices evidence-based care, and will send a mom home if she is not in active labor, so she can labor at home without the risk of unnecessary interventions. On the road, I got the confirmation (again from Joe) that they were staying.

As I rolled into town, I messaged Joe if they wanted anything from town: coffee, breakfast?

"Soy latte please," Joe wrote. "And Sue says she would kill a man for a coffee."

"Is 'coffee' code for peppermint soy latte?" I asked.

"It is," he replied.

I walked into our neighborhood coffee house and was greeted by Jill, who remembered me from my own infant-in-arms days, well before we moved two hours away. Because I was a regular, in the shop every day for something decaffeinated.

"Hey! What can I get ya?"

"Joe and Sue are havin' a baby, so I need to pick up a couple soy lattes for them," I said. "A medium soy latte for Joe."

"No, no," she interrupted, beaming. "Joe always gets a caramel soy latte."

"Oh? He did not say caramel," I pondered. "But let's go with the usual. And a soy latte with peppermint for Sue."

"That is so exciting! I saw Sue in here the other day and she told me she was past due but it's OK because she was past due with her first baby," said Jill, "and all I heard was past due... What if she had broken her water here?"

"Nah," I replied. "Only 25% of labors start with the water breaking." I do not know why I busted out the statistics.

"That's not what happens in movies! They always swoooosh, gush all over the floor, and then there is always yelling because there's only like ten minutes to get to the hospital before the baby plops out."

We laughed, and I left with the two lattes.

Birthin'

Arriving at the birth center around half-past 10am, I delivered the two lattes to Joe and Sue, who greeted them like undergraduates after an all-nighter. I learned that they checked in at around 4cm. Yes, it is funny to talk about time in units of measurement -- but when birthin', does time really matter? Then again, do centimeters? What really matters is how the mom and her partner(s) and the baby are doing. And here, they were doing splendidly.

Sue was standing and slow-dancing with herself during contractions, and Joe was browsing the web on his smartphone, coming over every few minutes to show off a hilarious photo -- like the one of the lemon giving birth to another lemon -- sending Sue into laugh-induced contractions. When she complained of sore feet, I asked the nurses for a labor ball. Sue sunk into the ball and moaned, "Oh yeah. That's the stuff."

Strangely, Sue had some back labor which was new to her, since her first baby did not give her such an affliction. Joe was delighted to push on her back, and was even more delighted to say obscene things about their position: her, bending forward and him, standing behind her with his hands on her tailbone, his arms locked, his feet planted firmly into the floor, and his back against the wall.

"This position was more fun before," he remarked.

"You're telling me, kid!" Sue smirked.

Between contractions, we talked about toddlers, about mutual friends, about babies, and, of course, about labor. "I can tell this baby is bigger than the first one," Sue said. "I think this one is 9 1/2 pounds. The first one was almost 9."

"We will see!" I said.

At 5cm, or 2:20pm -- a full six hours since her 4cm cervical check -- and after a long shower, with the hot water pushing on her back (after this, the baby turned and there was no more back labor), Sue agreed to break her water. In her first birth, the AROM (artificial rupture of the membranes) sent her into full-blown labor and she had had her baby a mere five hours later. We expected similar results this time.

The OB reached the crochet-like hook inside and ruptured the membranes. "There is some meconium in the fluid," she said. "We will have to keep you on the monitor for a few more minutes."

The baby was watched for a while, but the nurses saw nothing strange; thus, Sue was released to get into the large bath tub provided she keep the wireless, waterproof monitors strapped to her belly by a wide green stretchy band. This time, there was no tub in the room, but there was one a few doors down. Sue got dressed -- the hospital gown which covered her front only, the band that covered her stomach, and a pair of gauze panties with a pad big enough to soak up a small aquarium.

We ventured into the hallway: Sue, then Joe with Sue's water bottle, and then me with the camera. A nurse from across the hall opened her eyes very wide at me and made a closing motion with her arms. I looked at Sue -- from behind, of course, and saw the problem (the behind) -- and immediately closed her gown and held it shut on our short walk down the hall.

In the warm water Sue relaxed immensely. The "ooh" and "ahh" moans were back. This time, I tried the count-up-to-ten, count-down-from-ten method that I had found to be working with my most recent clients. Her instructions were to stop me if she did not like it. She never stopped me. So I counted up to ten with each contraction, trying to match ten with the peak, and counted down as the contraction subsided.

The lights in the tub room were insanely bright. I asked the nurse if she had any of those battery-operated LED candles lying around, but she could not find them. So I did the next best thing: I taped blue washcloths over the lights with some fabric tape.

Mood lighting meets
modern engineering

Transition is when the baby falls out

An hour after getting into the tub, at 3:45pm, the telltale pressure at the top of each contraction. I called the nurse, who called the doctor, who called Sue to get her out of the water and back into the room for an exam. The nurse was the first to arrive, followed by Sue, who got on the bed and draped herself over the top of it, on all fours.

"Seven and a half," the nurse said. "Call the doctor," she shouted over her shoulder.

One more contraction, when Sue puffed like she was blowing out candles at her 3000th birthday.

"Where is the doctor?" the nurse snapped. "When I say 7 1/2 centimeters, you get the doctor," she complained with a huge fake smile and a glance at Sue and Joe to the other nurse, who had just walked in.

Sue growled.

"Hm, why don't you try just going with that feeling," said the nurse. "Just push through it."

Sue pushed.

The doctor walked in, introduced herself, and asked if she could do a little exam. Receiving the affirmative, she reached inside and whispered, "I can't find a cervix. The head is right there."

Sue whimpered.

"Why don't you get on your back," the doctor said. "It will be easier for you and the baby."

Sue turned over, graceful as any mammal with a baby hanging between their legs.

"Joe is going to count to ten, and you are going to push for the whole time," said the doctor. Joe counted; Sue pushed in silence. Then a deep breath, and more counting, more pushing, for the duration of the entire contraction. Above: Joe and Sue's heads; Joe's soft voice counting. Below: the baby's head, molded like a walnut. I snapped pictures of Joe supporting Sue. It was nearly 4pm.

But then something happened

The room filled with people: nurses for the doctor, nurses for the patient, doctor for the baby, nurses for the baby-doctor. Everyone was watching the baby's heart rate. The machine should have been beeping, but it was not. Maybe the lead was off. We had been having problems with the monitor finding the heart rate throughout the labor. The lead was off. Right?

"Let's get mom some oxygen," the doctor commanded. A plastic mask was handed to us and Joe and I placed it over Sue's face. "It's for the baby," the doctor said.

The baby-doctor, Dr. Moss, a wholly unremarkable middle-aged man in plain blue scrubs, looked concerned, with his hands folded in front of him, as he watched patiently for the baby to emerge. His two nurses were unwrapping things behind him on the baby warmer.

One more contraction, and Sue's baby boy slid out. Neither Joe nor I saw it because instantly, the cord was clamped in two places and cut in under three seconds. The baby flew in Dr. Moss' arms to the baby warmer, where six hands simultaneously rubbed a grey and floppy form of a plump infant. I put down my camera. For the first time in any of my births, I did not feel my eyes water. I felt bone dry as I came up to Sue and Joe.

"Good job," I cooed through my parched mouth. "Great job. That was so good." But nobody was paying attention. All eyes were on the baby warmer. Something white flashed in the doctor's hands -- something I have come to associate with the term "intubate" from watching TV shows like House.

There was a wet, muffled cough. Joe looked at me and whispered, "What's happening?"

"I don't know," I said.

I could see the baby's chest being massaged from both sides -- top and bottom, and his grey, limp ribcage was dancing on the warming bed. And when the ribcage danced, the grey arms bounced about on the bed as well. He looked like a lifelike doll, bouncing and dancing to some unheard music.

"He is doing fine," said the doctor. A suctioning sound came from the baby. Nobody believed him.

I looked at Sue. She was looking straight into Joe's face. The doctor was draining her placenta. Then we heard the baby's first cry, and we could all breathe again.

The nurse said, "Joe, you can go to the baby."

"I can?" he said, and, squeezing his wife's hand tenderly, and with a kiss on her head, he went to the warming bed.

The baby's head and chest had gotten pinker, but his arms and legs were still grey. Dr. Moss lifted an arm, and it snapped back into its curled place, jiggling a little.

"He is doing better, but I don't like to see babies so floppy," he said, explaining. "I want to take him to the nursery for some tests and to make sure he gets better." He used small words.

Dr. Moss was making preparations to carry the baby to the nursery. An astute nurse asked -- and for this, I thanked her silently -- "Can the mom see the baby first?"

"Oh, yes, of course," he answered and held the baby out to Sue. This gesture reminded me of The Lion King, when Rafiki the monkey presented Simba to the animals in the kingdom. Held up for the subjects, high above them and far from them, to be seen, but not touched. I watched from behind and snapped a photo: an anxious, worried, pained mother longing for her child; and the wrinkled, chubby back of a limp, pinkish grey baby.

Rafiki presenting Simba to the animal kingdom.
(c) The Walt Disney Company, 1994--1995

"Do you have any questions for me?" asked Dr. Moss.

"No," Sue said.

I looked at Sue. "Do you want to ask when you can hold the baby?"

"Yes," Sue said.

"It's hard to say," Dr. Moss said to Sue. "After we draw some blood, and run some tests. I would like to say 45 minutes. But it may take longer."

"OK."

And with this, Dr. Moss ran away with a tightly-swaddled baby. Joe went with him, and I stayed with Sue.

A blur of Dr. Moss taking away the new baby

There was so much cognitive dissonance for me. On the one hand, every doctor and nurse were saying things like "He's doing so well," but on the other, nobody could touch the baby. And he was grey and floppy. If he were doing so well, he would be on his mama's chest, just like last time. And Joe would be cutting the cord, just like last time. What did it mean? Was the baby okay, or wasn't he?

The nurse said the baby likely inhaled some meconium. I looked at the remains of the umbilical cord. It was blue, not stained by meconium the way the cords get after they had been bathing in meconium for hours. So the meconium could not have happened too long ago. What did it all mean? And why was everyone using small words and saying he was so well, when he clearly unwell?

Physical repair

Sue's doctor was threading a curved needle and began to make the repairs. "Second degree?" I asked.

"Yes," she replied.

"Ah, like last time," Sue said.

"Yes, and it looks like you tore in the same place," her doctor said. "I can see the scar right here."

It was clear that Sue was in a significant amount of discomfort. Her doctor worried: "Would you like some more numbing?"

"It's not you," Sue replied. "It's just everything. I'm very sore. Ow! OK, that one was you."

We tried to have a sense of humor, but it was so grim in the room. The doctor finished her repair, and left. Sue turned to the side, away from me, and shut her eyes. I thought she was trying to sleep after her long ordeal: twenty-six long hours of early labor, and an hour and a half of the real deal. And then this.

I touched her thigh. "Do you mind if I go to the nursery and try to get some pictures of the baby? I have my phone. Call if you want me to come back."

Sue nodded, eyes shut. I went out.

Nursery

The nursery was a single room, attached to a the single operating room. Outside the nursery door, I saw through the mostly-closed blinds that inside, there were just two warming beds. Only one was occupied, with Joe and Sue's baby. Joe was rocking in the chair nearby and two nurses and Dr. Moss were doing something to the baby. A third nurse was at the computer, typing furiously.

I do not know what I was imagining a nursery to look like. Maybe like nurseries in the older movies, with a row of beds and a baby in each bed, and a large window to see in. This was a far cry from that image, and there was significantly less cooing over new babies.

A nurse approached the door and I asked her if I could go in.

"Are you family?" she asked.

"No, I am a friend," I replied. "I am Joe's friend. He is inside on the rocking chair."

"I will ask," she said, and disappeared inside. I stood back and read some things posted on the bulletin board while I waited. There was an article about a woman that had a c-section, and someone had left a surgical sponge inside her abdomen. The sponge caused several of her organs to fuse, and the court granted her over $500k in medical expenses, and the nurses were held responsible because they should have counted the sponges. They said they did, and it should be the doctor's fault because he was in charge.

The nurse returned and said that I could not come in because they were going to clear the room for a chest x-ray, to check whether there was any infection in the lungs from inhaling meconium. I thanked her (for what?) and headed back to Sue's room.

In the small waiting area, I met a white-haired woman wearing nice exercise clothes. I had seen her waiting, talking on the phone, and reading books on those couches several times in the hours since I arrived. I asked: "Having a baby?"

"Well, I hope so. We have been here all morning and things are happening very slowly. How about you?"

"My friend had a baby boy recently."

"Oh, how lovely! There was a baby boy born at 3, is that your friend's?"

"No, hers was at 4."

"Oh, two baby boys! How nice. Is he with your friend now?"

"No, he's in the nursery."

Her eyes lit up. "There is a nursery? Where you can see the babies?"

"Um." I did not know how to answer that question. I could have said, "It's where the sick babies go." Although not untrue and not really revealing anything about Sue's baby's condition, I did not know if it would be the wrong thing to say. Instead I said, "No, you can't see in, and there is just the one baby inside."

Sue's nurse came out of her room. Seeing me she said, "Can you do me a favor? Do you know where the baby blankets are?"

I confessed I did not. She explained where to find them, and that underneath the warm baby blankets are the warm adult blankets. Sue was cold. I rushed off.

In the room I found a frightened Sue. She had not been sleeping -- she had been terrified. I put the toasty blanket on her and sat by her head.

"I thought you were sleeping," I said. The room was dark, and the rain spattered on the window and the small balcony outside. Sue's room was silent and lonely.

"No," she replied. After a pause: "Everything hurts." And: "I want my baby."

"I know. Joe is with him. I was watching him watching your baby."

Emotional repair

Hours passed without any of us really understanding what was happening. The turning point was when the nurse suggested a trip to the nursery. This motivated Sue so much that she immediately forgot about her body's aches; with her nurse's help she got up, got dressed, and was wheeled in the chair to the nursery.

Joe was standing up over the warming bed with a finger in the baby's mouth. The baby was sucking beautifully. Joe said: "My finger is all pruny. This has been going on for hours. My feet are sore." We laughed. Finally, we laughed.

The baby was connected to a heart monitor, oxygen saturation sensor, breathing monitor, and an IV in his ankle, and the nurse was trying desperately to draw blood from any of the baby's four limbs, with little success. She had been trying for quite some time. With each needle-stick, the baby would cry briefly, and continue sucking.

"Do we have any sugar-water?" another nurse asked. "If you put some on your finger for him to suck, it's a natural pain reliever for the baby."

"How about we use breast milk?" I suggested, always the advocate.

"I'm not sure there is any in there," Sue said.

"That is a great idea," the nurses said, and gaily approached Sue. "Try it!" Sue tried expressing a little milk onto Joe's pinky and out came a copious amount of colostrum. And as soon as Joe put the finger into the baby's mouth, his eyes opened and he visibly salivated.

"He likes it!" everyone exclaimed.

Sue finally got to hold her baby, still connected to all of his tubes and monitors, at 7:30 -- over 3 1/2 hours after his birth. She held him and nursed him, though he was already drifting into a solid sleep. But in his sleep he would wake, nurse, and fall asleep again, snuggled skin-to-skin with his mama.

Conclusion

Every birth is different. How true this is.

Sue's goals for this labor were to complain less and to push faster, and she succeeded in both. She complained very little -- only in transition did a little complaint escape her lips (and who wouldn't, a little?) -- and she pushed for just fifteen minutes. One could say it was a better birth in this way.

But after the baby's birth, when things took a turn for the unknown, when the baby did not go directly on mama's chest but was instead whisked away, and nobody understood what was happening -- oh! how different it was than the first, picture-perfect natural birth.

You will hear, "What matters is a healthy mama and a healthy baby." While this is true, it is an understatement to the emotional roller coaster which is made more prominent by the mother's extreme hormone shifts after the birth of a baby. In the end, this story had a happy ending, though certainly not without serious worry.

What really happened? I guess this is something for Joe and Sue to figure out with their doctor. My part is to support them throughout birth, and my support will continue until they have closure.

Five hundred hours

2011-11-25T08:08:00.001-08:00

500 hours. That is the cumulative number of hours that I have spent speaking in front of a group. That is three summers I taught courses with 40 lecture hours each; 8 quarters of graduate teaching assistantship; and 10 quarters of undergraduate group tutoring where I led lab lectures for an hour once a week before one-on-one tutoring. That is six conference presentations (and four practice talks), one in-house research presentation, an advancement proposal, and a commencement address. That is two guest lectures in a graduate class, and one in an all-girls' day school. That is at least one trite talk for general-education requirements (I lost count after one, because it matters so little).

I am not so nervous about public speaking anymore. It really does come with practice.

Clinical data management: My response to a new technology

2011-11-25T02:08:00.001-08:00

Meanwhile in Austria, at the USAB 2011 conference on eHealth, hundreds of health and technology professionals gather to discuss topics relevant to information flow, patient empowerment, and clinical decision-making.

The first of four (four!) keynote presentations was given by Vimla Patel of Columbia University, whose interests lie in quality of eHealth data. In the talk, Cognitive Approaches to Clinical Data Management for Decision Support: Is It Old Wine In a New Bottle?, Dr. Patel argued that indeed it is new wine in a new bottle. This post chronicles my reactions to the talk. Dr. Patel, if you happen upon this post, please know that I am quite jet-lagged and had had three of the complimentary espressos, in rapid succession, shortly before your talk. I do not intend this as an apology, but as an explanation, and as a hope that you will not hate me for expressing my views so plainly. I don't buy it, and here, I explain why.

Patients are in danger!

The problem was outlined thus: Information technology impacts patient safety. There is simply not enough evidence that current information technology systems are good for patient safety -- in fact, they might be detrimental. One of the reasons is that there is no accountability for these systems. According to Dr. Patel, in many cases, systems are designed and deployed by engineers without consulting with clinicians or patients, and without proper responsibility for upkeep of the systems for new ideas and trends.

Federal regulations

A way to address this? Dr. Patel suggested: Technology should be monitored by an agency or government; there should be federal regulations on software released for eHealth purposes.

Pardon me while I gather my jaw from the floor. Right off the bat, I can think of at least two reasons this will never work.

First: The design-development cycle would be too cumbersome. Can you imagine being the poor programmer that has to succumb to federal regulations, to laws and restrictions, to government-imposed checks and balances? Can you imagine trying to add a new feature, a new decision flow, or a new interaction method? I thought the Apple Developer cycle was bad; this would be murder.

Second: Regulations on software are restricting. No, I don't have a citation for this, you overachiever. I know from my experience and from the experiences of all of my colleagues that regulations are inversely proportional to success of a software product. While it is true that some restrictions spark creativity, what we are talking about here is a severe impediment to the development process.

Here's a bonus: Third: Every hospital, every office, every provider has different requirements. How do you federally-regulate this difference and custom instances of the same product? It is a nightmare.

Why Electronic Health Records (EHRs) suck

Problems with current electronic health record (EHR) system include the following.

In EHRs, information is structured temporally, which is how clinicians come about gathering the data. As a clinician, you see a patient, you take notes; you see the patient again, you take more notes. Over time, this presents a time-oriented view of the patient's health. But the problem is that clinicians do not think about patient health in this way. They think in terms of symptoms and relationships between symptoms, tests, and diagnoses.

So the question is how to store the data in a way that is fundamentally useful to clinicians, and how to retrieve and display it in the same way that they think about the data. There is too much data, too much redundant data, and too many sources of related data. There is a mismatch between cognitive processes of clinicians and the way the data is stored and represented.

The result Dr. Patel drew is that there is poor usability study and requirements gathering for these EHR systems. By involving users (i.e., clinicians) in the process early and often, she argued, we can explicitly retain the relational structure in software that clinicians use in real life: a complex mental model of vital signs linked to symptoms linked to potential diagnoses. A directed graph of thoughts and decisions. Understand what people want, she said. Test iteratively with users, she said.

I thought: Don't be afraid to say participatory design.

User study is not enough

Dr. Patel never outright said it, but it is a question of tagging and metadata and, most certainly, provenance. In effect, the question is the same as in any large-scale file system (think peta-scale): how can you predict which data the user will want to retrieve? I refer the reader to work done by the Storage Systems Research Center which has been tackling the problem in full force.

Sure, representing the data is important. As with any file system (let's face it; that's what we are talking about here), we can know everything about what users want, but it may be fundamentally impossible to deliver this kind of system. Big data have an inherent bottleneck at retrieval; they have an inherent bottleneck at storage and archival.

Nobody likes to be wrong

In real life clinicians draw logical conclusions in a guess-and-check fashion: given a set of symptoms gathered from charts, nurses, attendings, and other sources of information, they make a mental model of the potential problems and solutions which can be confirmed or refuted. In the ideal scenario, the clinicians would chart these decisions and potential diagnoses. They would chart, in this system, anything that they considered potentially important in the future.

Oh god! So many problems!

First, think about the paperwork overhead. Electronic paperwork, whatever. Sure, in the ideal world with infinite time and infinite memory (as they say in computer science), doctors would save all of their thoughts.

Second, think of the liability. I am not even talking about not wanting to be wrong, which, of course, everyone feels. It is well-studied in elderly patients with dementia: they will not admit to forgetting appointments or missing meetings. People won't chart wrong guesses. Being wrong is bad. For a clinician, being wrong leads to liability. Mis-representing a symptom that can lead to a missed diagnosis leads to liability. How can you prove your motives were good, when the patient's health was compromised?

Third, is this another way to minimize patient interaction? Look, in labor and delivery in the US, the average doctor spends something like 2 hours, 41 minutes with her patient, total, throughout her entire average 10-month pregnancy and including the 24-hour birth. With such a system, will it mean that a doctor no longer needs to spend quality time with her patient, but instead spend this time mining data? I do not argue that in aggregate, data gathered over time in a particular facility can be powerful. But what happened to patient-centered care?

It's different on paper

Electronic health records have a different set of abstractions and information flow (and hence, a different set of mistakes one can make) than paper-based ones. For paper-based health records, it goes basic concepts (such as vital signs) : intermediate constructs (what to do with the vitals: e.g., compare to normal, compare to expected, compare over time) : heuristics (visualization and diagnosis). Concrete to abstract. But most experts do not bother writing down some basic concepts because it is inefficient, much in the same way you do math in your head or play chess without writing down the possible moves. For EHRs, the flow goes heuristics : intermediate constructs : basic concepts. Abstract to concrete. The overlap is at intermediate constructs, and the question is how to move them from the head to the computer.

I imagined WebMD, the website that spits out a list of things that could be killing you subtly or not-so-subtly, given an input of real or imagined symptoms. The output from WebMD is potentially useless. You have a stomach cramp and a head ache? It could be a brain tumor and pregnancy.

Disempowered

Of course, the tool Dr. Patel described would need to be understood by a doctor, or someone else medically trained. In fact, she said, in some cases, you do not want the patient to know at all. There are cases that the patient should not have access to these private thoughts of doctors. With the exception of one situation which I do not have training to understand, namely, adolescents seeking psychiatric care (if I were said patient, I would damn well like to know what the doctor thinks!), I thought that it was a huge oversight that the system would be unusable by anyone without proper training. Make it understandable, she said, for the doctor.

What about patient empowerment? What about patient information? In Germany, a doctor will sit alongside the patient to look through a clinical workflow, and they will decide together, collaboratively, on the proper treatment. Why is there not more of this worldwide? And why not just teach the patient?

Dr. Patel said the goal is to move towards patient-centered cognitive support for the clinician. I realize that this is the goal, but with this technology, I worry that we are removing real interactions between the clinician and the patient in favor of data collection. We are in a digital age where we teeter on worshipping data: in some ways, we hold data above all other things. We hold data collection, for example, above the real-life interactions, the real time that doctors and nurses used to spend with patients, that now they spend writing down things about their brief encounters.

Finally, and then I will stop ragging on this keynote, what about evidence-based medicine? Why has it never been mentioned, alone or in conjunction with "patient-centered" care? Why are we increasing the burden on care providers while decreasing the burden on the very people that are meant to do well -- by removing them from the patient and treating their thoughts, education, and logic, which makes them unique and valuable, as interchangeable with any other doctor, clinician, or robot?

Now, take this with a grain of salt because my triple caffeine buzz is wearing off. I was pretty excited about this talk when it began: the initial idea was that medical technology, and electronic health record systems in particular, are possibly doing harm to the patients they intend to serve. But near the end, it was clear that the only take-away, for me, is that more user study is needed for electronic health records, to determine what doctors need to make them disposable. As a patient and as a researcher, I feel disempowered.

But it is an interesting file systems problem.

How to get my number at a tech conference

2011-11-15T10:37:00.001-08:00

In technology, the male-to-female ratio strikingly favors the males. Of course, it depends on the specific field how rough it is: game design, for example, has more women than semiconductor research; human-computer interaction has more women than systems and security.

Having just had come from Grace Hopper Celebration of Women in Computing I was keenly aware that at Supercomputing 2011 the ratio was not 2:2900 (I think there were a few men at Grace Hopper) but more like 150:11. Yup, I counted, sitting in the back of the room where my workshop was being held. Interestingly, there were five of us students from the same university at this workshop, and four of us were women.

My talk was third in a block of three, and the latter two were similar in that they stemmed from the same set of interviews and touched on similar topics. After my talk, there was discussion in the audience, and when I rejoined my university's group of students, we began being approached by researchers interested in our work -- with comments, suggestions, and questions.

A young man, probably a few years younger than me, in a white and green graph-paper-patterned shirt, wearing dark-rimmed glasses on his long nose, and his hair cropped in the typical defense-industry fashion, approached me and my female colleague.

"I work on the very system you were studying," he said. "I'm the guy. I run everything, set the policy, and have tons of data on it."

"Hang on! Stay right there!" we exclaimed in unison. In a flash, my colleague and I ran off to retrieve our business cards. Tons of data! An expert in the field we are studying! This was very exciting. I ran back to my chair where I had left my laptop and bag, grabbed a stack of cards, and ran back, nearly knocking over chairs in the process. I saw my colleague also rushing and rummaging.

I made it back first. Presenting my card to him (American-style), I said, with a smirk, the first thing that came into my head:

"You just discovered the best way to get two women's numbers at the same time."

He looked at my card, and looked at me, and I could see that he was trying to determine whether what I had said was shocking or funny. I laughed.

Just a disclaimer that it was a joke.

But if you meet me at a tech conference, now you know how to get my card.

The Thin Line: Advising vs. Supervising

2011-11-11T16:01:00.001-08:00

This is a post about the session The Thin Line: Advising vs. Supervising at Grace Hopper Celebration of Women in Computing.

The panelists: Laura Dillion has spent decades advising students at three different large universities, and spent time as department chair. Susanne Hambrusch has experience dealing with situations between students and advisors that went from bad to worse. She says that just knowing that a situation can occur is important. Lori Pollock has had experiences being the unbiased mediator between graduate students and their advisors.

Can I be co-advised by two professors? Can I switch advisors?

Sometimes switching advisors is controversial both in terms of your own work and in terms of the political climate of the department or school. Consider your own work, which may or may not move with you to the new advisor or department. It likely won't. Figure out if you will still have a project, and enough to do in order to graduate with a big dent in the new field. If there are concerns (and there should be), find someone that doesn't have a stake in the problem, and ask him or her for help. Someone unbiased can provide valuable advice. It could be a former instructor, a graduate advisor, or even more senior graduate students. Some students don't ask for help. In some places there is no help. That's where you should turn to other sources: e.g., friends' advisors, family, the Systers mailing list.

How and when do you ask about the author order and/or about presenting the paper?

Talk about it early. It can change, but know before you invest a ton into a paper how much credit you'll get for the work. Three possibilities are alphabetical order, percentage of writing done, and switching author orders if you expect more than one publication.

How do you know what your research contribution is on multi-authored work, and what you can present as your own work?

This is a good question in interviews, so make sure you have a well-reasoned answer: your research is your identity. The abstract of your dissertation, and your introduction, should make it very clear the different roles. Co-authored and multi-authored work can become "background" for a dissertation, and some papers never make it into anybody's dissertations. Think ahead: the part that's yours is the part that you will continue when you graduate. Be scrupulously honest.

My advisor keeps giving me more work, and I want to schedule my dissertation and graduate.

Ask. Sit down with your advisor(s), and have the conversation. Don't wait until after you've done the additional work to ask, but ask right then. Show your credentials: the number of papers you have, your advancement proposal which has been fulfilled, the chapters you've written, etc. It may the case that you aren't ready to graduate, but it may be that you are. It may be that you have differences in expectations (e.g., your advisor thinks you want to go to an R1 research institution, but you want to go into industry) which have serious differences in preparation for graduation. You won't know unless you have that conversation with the advisor.

What if my committee doesn't think I'm ready, but my advisor does?

Your advisor is your advocate. He or she needs to convince the committee that you're ready. There are no hard-and-fast rules to follow: you may want to look for a mentor for an outside, unbiased opinion.

What if my advisor is a total jerk? (This question was truncated and summarized.)

Find someone that can advocate for you. Go to the other faculty. But don't go straight to the dean, going over the head of the senior faculty and department chair, because this can cause bad feelings and really burn bridges. Learn about what's possible in your university and what resources you have. Sometimes it takes intervention for your advisor to do change; sometimes you have to switch departments and get your work to count toward your new affiliation. But get support from the senior people in the school that have influence.

What if my advisor lost his or her funding, and has no more money?

Understand that this could very well be true: the faculty member may have thought he had secured money but the money didn't come through; he or she could have overanalyzed the financial possibilities for the quarter or the year. Sometimes the money just disappears, such as with government contracts. It is embarrassing to the advisor, especially when the advisor had already made plans on the money (such as by promising you funding). Consider going to the chair or graduate director. Take up a TAship, teach a summer class, or find other sources of funding around your department or even in a different department.

How do you transition from being a student to being an advisor?

First you have to find a job in a supportive environment. Attend the CRA-W workshop for junior faculty in which they teach you how to be a good mentor and advisor. Have a mentor in the department that you join, that can help you along. Don't do it as trial an error, one student at a time. As a graduate student you can work with undergraduates in the summer on collaborative projects, and practice advising and mentoring.

Connecting the Disconnected: Improving Internet Access for the Other Four Billion

2011-11-11T10:01:00.001-08:00

This post is about Connecting the Disconnected: Improving Internet Access for the Other Four Billion with Professor Margaret Martonosi from Department of Computer Science at Princeton University, at Grace Hopper Celebration of Women in Computing.

Information technology is an enabler. It is an enabler in education - for people to learn, through online courses, articles, and things in the public domain; in health care - getting an ultrasound when needed; in agriculture - the ability to find out why your crops aren't thriving; and in open and fair government - the ability to discuss politics openly with other people.

This presentation was about C-LINK, a type of delay-tolerant vehicular network. (Note: This vehicular network is an example of Sneakernet, though I don't think Margaret ever called it this.)

The current state of universal connectivity

Sure, the US is connected. Over 75% of the country has wired or wireless access. But there's the digital divide. The digital divide means that the places that need this technology the most are the places with the most impaired access to it.

The three factors influencing universal information technology access includes relevant and accessible software, using effective and affordable hardware, and have universal connectivity. C-LINK, Margaret's project, was influenced by all three.

The problem with affordable hardware is the "last mile" problem: it is easy to connect the majority of the people, but in the last mile, you have to extend connectivity to rural or hard-to-reach regions. This can be complicated, and costly. In rural Africa (for example), the last mile is of a whole different scale. So then we consider wireless technology, which is expensive, we need to think about how it still needs a wired backbone, requires ongoing maintenance, is subject to corruption or salvaging (because copper sells), and it needs political support. On the other hand, wireless technology is leapfrogging wired connectivity (especially in developing regions). Mobile and cellular is a big growth area and are increasingly penetrating the world. But even though there is so much cellular technology going on, that doesn't mean that it's cheap.

Let's look at effective and affordable hardware. Although there are efforts to build cheap hardware (such as the hundred-dollar laptop made by the One Laptop Per Child organization), it's not taking off. It's just not pervasive -- most of Africa and Asia have less than 10 computers per 100 people. That's even when you consider microcontrollers as "computers." So what is the world's computer? The world's computer is a cell phone. About half of the world's adults own one. There are more cell phones in India than credit cards -- and cell phones, even when they're not smartphones, are chock full of interactivity. (Note: Can you imagine an accessible Qwiki for developing nations that works over SMS? I can.)

Connectivity

Wired connectivity: availability is increasing and costs are dropping. For example, transit prices in Kenya have dropped to $120/Mbps -- which are similar to US prices in 2003.

Delay-tolerant network: Imagine a big city with a broadband connection, and a nearby village. Imagine that the village is on some rural bus or taxi route to the city. Now, imagine that the bus has a laptop inside, with a large hard drive and a wireless access point. People (and goats and chickens) board the bus in the village, send some requests on the laptop. Although the laptop isn't connected to the broadband, it can queue the request and send it when it reaches the city, and bring back the reply when it returns to the village. If the bus visits the village every 5 hours, that's a 5-hour latency -- but at least it is access to information.

Never underestimate the bandwidth of a station wagon carrying tapes hurtling down the highway. -- S. Tanenbaum

The vehicular delay-tolerant network is very low-cost, easy to deploy, and has a very high data carrying capacity. Villagers can collaborate on their queries, and the results can be available to others in the village doing similar web searches (called collaborative caching). The system can also be improved by clever prefetching -- the computer on the bus can be thinking hard over the next several hours about what else can be proactively fetched based on the current queries. Clearly, prefetching all of the links on a page would be smart, but maybe so would translating a page from a local language to a more commonly-used language. This isn't a microcontroller with a tiny cache. This is a big hard drive. If the hard drive is huge, there is no worry about performance loss in prefetching things that will not be used, but the overhead of not having things that may be useful is huge.

"Come back tomorrow. Your data will be on the bus."

The authors designed, built, and tested C-LINK, the vehicular delay-tolerant network, over a week in Nicaragua. The city was Somotillo, Nicaragua -- no skyscrapers, but there was a school with a computer cluster and wired connectivity and a small, expensive Internet cafe with 2 computers. Participants were school children, invited to come in and browse the highly-delayed web. About 80% of the participants in the project had never used the Internet before. One of the cool things that the project looked at is when participants sent at the same query, or searched collaboratively. With each successive trip into the village, the bus brought back more data. As the village's cache filled up, users' miss rates plummeted. Data were on their computers or on the computers of their collaborators -- remember collaborative caching? The authors found that highly correlated access patterns provided strong incentive for collaboration. Oh, and we can evict old data or data that has not been accessed recently. Any cache eviction policy will work here.

Then Margaret and her team considered using laptops and other mobile computing devices and, despite the worry of data loss, found that going mobile wasn't so bad. If anything, it made for more kiosks -- little hubs for collaborative information. Then, they found that the requests for data were fairly small, so it was possible to exploit cellular connectivity, where available. They looked at data brought back by the once-a-day trip into town, by the 5-times-per-day bus ride, and a hybrid data retrieval mode by combining these with exploiting SMS.

Look around you

Other software that the authors found interesting and noteworthy included these.

TEK is an e-mail-based web browser.
M-Profesa helps Kenyan children prepare for the secondary school test through SMS.
Ushahidi, also originally Kenyan, helps with crowd-sourcing of information.

Getting more involved

Imagine what you could do if you could alleviate teacher shortages by having better distance learning technologies. Imagine what you could do if you could have better information flow and expose corruption in the government. Get involved in Engineers Without Borders and attend Development conferences, such as ACM DEV 2012. Make a company. Build stuff!

Community College Women in Computer Science: A Study's Preliminary Results

2011-11-10T15:46:00.001-08:00

This is a post about Community College Women in Computer Science: A Study's Preliminary Results at Grace Hopper Celebration of Women in Computing.

The authors present their preliminary results from studies from community college students around California, aiming to answer the question what makes community college students transfer to 4-year university? That is: What factors determine whether community college students enrolled in a CS1-like course intend to study computer science at a 4-year university?

True or false? There are different motivations for males and females in pursuing computer science as a major, and women just don't value computing. The answer is false. Men were found to have great expectations for success with computing, but there were no gender differences in how much students value computing.

True or false? Family support is critical in choice of major and parental pressure is based on gender stereotypes. Also false. Family support was not critical, but peer encouragement was very important for both women and men in pursuing science.

True or false? Women's under-representation in computer science majors is due to lack of computer use an lack of computer game play. This one is true. Intention to pursue computer science was very important, and exposure to computing and computers (including gaming) was associated with intention.

The authors presented work collected over a true longitudinal study over two years, looking at demographics as well as social factors that may influence students' staying in computing after community college. They sampled the students three times: at time of enrollment, half-way through the program, and at the end of the two-year program.

Women were more likely to be older, have had a degree already, have a mother working in computing, and have had a programming mentor when enrolling in the introductory programming course, compared to male students. Whether or not a woman was comfortable talking to her professor did not affect her intention to pursue computing (and the other way around). Women thought computer programming was like thinking.

Men had a greater intention to pursue computer science at a four-year university, were more likely to play video games longer, and have mothers with no BS/BA, compared to female students. Men thought computer programming was creative.

How do we increase the number of women in computer science?

1) Men see computer science as creative, but women don't -- they see it as thinking. How can we bring creativity to women?

2) Men are influenced by computing experiences, including video games, in their intention to pursue compter science. How do we use games to help intention to pursue a bachelors (or higher) degree in computing? How do we get gals into games? How do we provide early programming opportunities to gals?

3) Men report that they get more support from their peers. How do we encourage peer support for women?

And this leads to the awesomest idea of the conference:

How do we use video games (especially competitive ones) to bring early interventions to women?
I'm envisioning a League of Legends clan for high school girls!

What if... You Thrived on the Tenure Track?

2011-11-10T10:11:00.001-08:00

This is a post about What if... You Thrived on the Tenure Track? at Grace Hopper Celebration of Women in Computing.

Ceclia Aragon took a 14-year leave from graduate school. In the time, she had two kids, was a stunt pilot (yup, in air shows), and worked for NASA. When she was a little tired with the life of a badass rockstar, she finished her PhD and got a tenure-track position (she is now tenured). She gives some advice about organic networking: It's easy to say that you should hang out with important people. But what do you do when you're shy? "I hang out with my friends, and now, guess what -- my friends are now important people." She says that the life of an academic suits her perfectly because it lets her pursue the things that are interesting and to truly find balance in her home. Jobs are more flexible, interesting, and fun at the top of the food chain, she says, and you work just as hard as in lower-level, less interesting jobs. "Life balance works well when you have that kind of autonomy."

Magdelena Balazinska has a lot of accomplishments, but also a lot of failures: grant rejections, paper rejections, proposal rejections. "Just don't list those," she says. Focus on the positive. She shows pictures of the house she and her husband designed and built, and her two children in various stages of infancy and toddlerhood. How does she manage? "I get help from anyone who's willing to help! I do what I have to do, and I ask for what I need." She flashes photographs of her husband with a baby during one business trip, and her mother with a baby during a conference in Greece where she had to present. NSF panel in Washington, DC? No problem -- a photograph of her and a baby outdoors with an explanation: "You can just call in, and then nobody sees how you nurse your baby!" Magdelena says, "I don't try to be perfect. I just do what I can."

Following a different path, Anne Condon was an assistant professor when she was barely 25 years old -- and now her daughter, whom she had when in her first faculty job, is attending Grace Hopper Celebration. "For me personally, the combination of the academic life and the family life is fantastic." Anne gives some advice:

Work on important problems, because the unimportant ones aren't interesting and just aren't worth your time.
Communicate effectively -- and if you need to bulk up your public speaking skills, it's never too late.
Enjoy teaching others.
Build strong research support networks. The research community is just not that supportive, she says. "You might give a talk at a conference and there might be 20 people in the room, and 19 of them are on their laptops." I think she looked at me, here, as I typed out that phrase. Oops.
Persist in the face of challenges; and, of course, go for it!

Natalie Jerger just finished her 3rd year review on her way to tenure. She suggests that one of the most important things is to find a supportive partner. Next, set your priorities. For her, she and her husband always eat dinner together -- this is an important thing for her. Last priority? Cleaning the house. "Both me and my husband are professionals. We don't have time to clean the house. We don't have time to argue about whose turn it is to clean the house. Hire a cleaning lady." Professionally, seek out and work on problems that you find interesting -- problems that you are passionate about. Develop a support netwrok and find good mentors, those whose interests and priorities align with yours. Finally, practice saying "no" so that you aren't stuck in a situation that you don't enjoy.

Jodi Tims, when she was 4, taught her friends about arithmetic -- that's how early she knew that she would be a professor. Like Magdalena, Jodi took a decade to finish her PhD. Violating all her advisors' rules about what one should do while in grad school, she worked full time as an instructor, did her academic research, and had two children. "You just find a way to balance that together," she said. Her advice for aspiring academics:

Accept advice of good mentors. This is as much about receiving good mentoring as it is about learning how to give good advice: "One day you wake up and realize, 'I'm the mentor!'"
Don't underestimate your potential
Focus on your students. Mentoring your students is a form of teaching, and this is a service that you need to provide to your students.
Know your institution. You don't have to make it work if your expectations are not met.
Get involved beyond your institution. This is where opportunities come from, to grow as a person and as a researcher.
Appreciate life beyond work. Family and friends make life worthwhile.
Enjoy the ride!

Questions were presented on index cards from the audience.

Q: How did you make the choice to go into academia?

Cecilia: In academia, you get to determine what is important. You choose to perform research that has impact.

Magdalena: Apply everywhere, and make the decision with an offer in hand from both industry and academia. The interviewing process is a lot of fun. The reason I went into academia because the interview in academia was more fun than in industry. One of the huge advantages in academia is not only that you get to pick what you work on, but also who you work with.

Q: We all know that tenure-track positions are hard to get. Should we accept non-tenure-track positions (postdoc, industry), or hold out?

Cecilia: In 2004 I wanted to be a faculty member, but I wasn't ready (by publication count and preparation). I took a job in an industry lab not really knowing if I would make the transition. But I worked on making my CV look like I was an academic while keeping up in my industry job. I wrote papers and attended academic conferences that came out of novel research in my job. Choose the industry position or the post-doc that will be most suited to your goals. Have a deliberate plan.

Jodi: There are lots of schools out there that are not the R1 institutions. If you really want to get into academia, consider going to lower-tier institutions. Maybe the pay isn't as good, maybe you start on a non-tenure-track position, but keep your mind open to other options.

Q: Do you really need a post-doc nowadays to get a tenure-track position?

Anne: As someone that went straight into such a position without a post-doc, I think it's a good thing to do. There is a maturity process that happens over that time; you meet different people and you investigate other institutions. I encourage you not to rush through things if there is no reason not to.

Cecilia: That's a great answer. I have seen people that have gone straight through. If you do it right from the very beginning of your PhD program -- you are publishing 2 papers in top conferences, you're networking with the top people in your field for 5 years -- then yes, you can get such a position. But if you're like everyone else, you don't have the pedigree in your publication record, then yes, take a post-doc. But make sure you choose your postdoctoral mentor carefully: they can make or break your career. A post-doc is an apprenticeship. You're getting paid less than you're worth. But on the flip-side, you're getting priceless mentoring from someone that's going to show you the ropes and make you very marketable.

Q: How do you make the choice between academic offers, or between a research lab versus a university?

Magda: If you have no other constraints (e.g., personal ones), go to the best university, because you will work with better students. The better the students, the easier it is for the faculty to do well.

Ioana: Go where the smarter people are and where there are more opportunities.

Cecilia: I put together a matrix of things that were important to me. Vacation locations, startup package, what my family liked.

Natalie: The people. Colleagues. Also, my husband was leaving his job so I wanted to go somewhere that he had a choice

You have to go home every night and still be happy.

Q: Cecilia, you are shy. How do you overcome this and how does it impact your career?

Cecilia: Yeah, I am shy. I miss important connections, and I just accept that. I know that when I started interviewing, I did not mention certain rare accomplishments that few academics achieve, and I didn't mention my highly technical background in mathematics and algorithms. The unsurprising feedback was that I wasn't technical enough, and I didn't get an offer from this institution. I told myself that for future interviews, I'm going to brag, even if I don't like doing that. I felt like I was acting kind of like a jerk, but I got offers. It works.

Q: How do you publish, write grants, mentor students, etc., in your first years?

Natalie: At first, it was terrifying. Teaching can suck up a lot of your time because it's the most urgent thing. The hardest thing is to make time for the thinking, to think about problems, solutions, and what you're going to do next. I think I messed up my first student. And have someone in your life that can give you practical advice when you're stuck.

Q: How do you deal with stress?

Jodi: It's actually a very important question. If you don't deal with it, it will impact everything that you do. I have to get out and do something: ride my bike, go to the gym, jump on the treadmill. And then I go do something else, make myself some space to think about something else. Then things fall into place and things don't look so bad as when you left them.

Magda: I talk -- to my husband, my family, my friends. But not colleagues. That's why it is so important to have family and friends.

Q: Family is my first priority. I want to be a professor, but the 7-year tenure time is prime baby time. I'm afraid that my male department won't like my priority of family dinners and baby-having.

Cecilia: Men, when they have to take care of a family obligation, they say, "I'm busy." Women say, "I'm busy, I have to go take care of my kid." So when you have to go take care of a family obligation, be more like a man, and say: "I'm busy."

Magda: I work and work and work, and at 5, I say, "I have to go." And I leave. And guess what, a lot of my male colleagues have to go too. And after the kids are in bed I work and work and work. Maybe I don't sleep always as much as I used to, but it works for me. And when I need to, I do sleep.

Ioana: Having family as a priority is not a problem. Being confident and admitting that is the way to go. I wouldn't want to be hired by a family-unfriendly institution. I was very open about my 2-body problem in my job search. The places that were not very accommodating, I did not consider.

Q: What advice do you have for someone applying for a tenure-track position with a partner? It's a 2-body problem with a similar area of computing.

Anne: I think it's good to bring it up reasonably early with the institution. If one of you has got an interview, that is a good time to bring it up. You may want to wait until you have an offer, but it is better to let them know sooner so that the university can work on this issue. Institutions need time for this. There are other options: a short-term position that can turn into something more permanent; maybe there is industry nearby. Be flexible but know what you really want. For the university, if you can attract two great people to your institution, it's amazing.

Q: What are you proud of that you have done outside your academic career that you wouldn't have been able to accomplish without an academic career?

Jodi: My academic career allows me to be flexible to do things like pursue mentoring with ACM-W and Grace Hopper Celebration

Anne: I got to take on many projects of national scope, such as the distributed mentor project and work through the Computing Research Association (CRA).

Grace Hopper '11 checklist: Five things to do at GHC11

2011-11-08T11:55:00.000-08:00

Grace Hopper Celebration of Women in Computing is basically a giant lady-party in which all of the conference attendees are gorgeous, brilliant, and interesting. But you already know this, because I have blogged about Grace Hopper in my post about do-overs next time I go, and in my post from my attendance in 2009. That is not totally right -- it is not just a party. It is an opportunity to showcase your work, learn about other women's research, find out ways to bring more women into our field and make it more woman-friendly, meet new people, and build lasting relationships.

Here are the top five things that I wish to get out of attending Grace Hopper Celebration this year, in 2011.

5. Reconnect with old friends

It has been a year -- in some cases, more -- since I have seen old acquaintances, friends, and mentors. From my first room mate, to the professor that has changed how I see myself as a researcher, to the group of 200 women that have given me the gift of working with my rockstar undergraduate student, I look forward to seeing these ladies again.

4. Find a collaborator

Researching alone can be dismal. Would it not be fun to meet someone with similar interests, in which we can complement each others' strengths? I have this rosy dream about collaborating on a paper with someone I had met once (maybe twice) at Grace Hopper.

3. Meet a new mentor

My career will soon be in flux: next year, I will be dissertating while on the academic job market. (Note: Even though Blogger doesn't think "dissertating" is a word, it totally is.) I imagine I will be in need of new guidance -- of help finding appropriate job openings, navigating the complicated job-seeking and application system, and finding the best way to present myself to particular universities. What better place to meet someone that can potentially help me than at Grace Hopper?

2. Make a new mentee

(Note: Blogger doesn't think "mentee" is a word, but if it isn't, it should be. It's who mentors advise!) As a senior graduate student in her final throes, maybe -- maybe -- my experience can be valuable to someone. I have an undergraduate degree with two majors, I worked in industry for 3 years, I had a baby pre-advancement in graduate school, and I work in a highly interdisciplinary field doing research of my own invention. I write grants, I write blog posts, I invent eHealth learning methods, and I play video games. Surely I could be a resource to somebody!

1. Say thanks

I am pretty lucky that in four years of attending Grace Hopper, I have never paid for the visit myself. In three years, I have never paid for child care. In two years, I have contributed to the program at Grace Hopper, hosting sessions and panels. I feel privileged that I have helped shape the community of women that I am about to see again, meet, or just observe. So, at Grace Hopper this year, I plan to say thanks for accepting me as a part of the package of women in computing, of technical women.

If you will be at Grace Hopper Celebration of Women in Computing in Portland, please find me and say hello! I will be tweeting as @lexyholloway.

Women, video games, and stereotype threat

2011-10-30T19:23:00.000-07:00

How does being a woman affect my perceived ability to, as they say, pwn it up in video games? Secretly, I feel a huge pressure to do well, and feel that I constantly fail to achieve not only mine, but everyone else's expectations for me as a member of a multiplayer team. No one is more surprised than I am when I capture a point, destroy an enemy, or execute a plan. I tell myself that it must be an accidental and temporary victory. What is it that renders me unable to believe my own accomplishments in game, and how do I deal with these feelings?

In a recent meeting of women scientists and engineers on our college campus, we discussed stereotype threat and how it can affect women. Stereotype threat is defined on Wikipedia as "the experience of anxiety or concern in a situation where a person has the potential to confirm a negative stereotype about their social group." How susceptible one is to stereotype threat depends on a few things:

How much one identifies with a particular group;
The negative stereotypes society places on that group;
Knowing about (2), and not knowing how to counteract stereotype threat (e.g., by just knowing thine enemy).

Some examples of being touched by stereotype threat can include women that believe that women are supposed to underperform on math tests compared to men; African-Americans that believe they ought to under-perform on graduate entry exams; and, well, women that believe they don't belong among their male peers in video games. When left unchecked, stereotype threat can develop into self-handicap and other types of self-fulfilling prophecies: You believe you will do poorly (maybe because you believe everyone else believes you should do poorly), and so you do. You study less, you practice less, because -- what's the point? -- you will still underperform because it is destiny. And if you do not do poorly -- if you did well, if you exceeded your expectations? The thinking goes that it was clearly a mistake. You are an impostor in your field.

It is not destiny.

I will just out and say it: I am a gamer. Whew. Just writing that makes me feel all sorts of awkward. Because in my head there is a doubting monologue: Am I a gamer? But I'm not good. I'm not that good. I'm actually pretty bad. In fact, I'm worst on the team. We lose because of me. I spend most of my time dead or making bad choices, or both. It's probably pretty dull to have me on the team. My playing frustrates my teammates. People play with me out of pity. It goes on and on and manifests itself in other ways: for example, if a teammate types something mean in chat (such as "wtf, noob" -- code for "you idiot"), I start looking around furiously for what I have done wrong.

This is the game at which I allegedly suck.

And here is the weird thing. Nine times out of ten, I have done nothing wrong, and the comment is not intended for me. A quarter or even half the time, I am among the top three players on my team. People still play with me.

Why is this surprising to me? I come from a long line of anti-gamers. With the exception of my grandfather, who played chess, a socially-acceptable game, none of my family looked kindly on games and the people that play them. Moreover, there is the rest of society: Women should not be gamers. And if they are gamers, they should be really good, like they always are in the webcomics about gamers. They should be pro-level. They should be so good that nobody dares to challenge them. I am not making this up -- do a quick search for "woman gamer." I am not like any of these women.

In the women in sciences group meeting, it occurred to me that I expect the worst so that I can be pleasantly surprised in the end. I do this in classes, on exams, in grants; to some extent, in my conference publication submissions... and in video games. I expect to be worst on the team, and when, at the end of the game, I discover that I was not worst (or better) -- well, it is cause for celebration! Right?

But it is more complicated than pure joy at the surprise: The feeling sours quickly. I feel that it is a fluke. Somehow, the statistics engine generating the score had a malfunction. It missed a few of those times that I fired the missile in the wrong direction. Or teleported on top of an enemy and died instantly. Or forgot to use my very powerful weapon ability. Video games are a strange place to find impostor syndrome, but there it is.

Of course, none of those thing happened. There was no fluke in measurement. I really did perform as well as the statistics say I did: nine kills, four deaths, ten assists. Number two on the team. Really. Why is it so hard to acknowledge my own success? Because there is no way I am as good as my male peers, and I am nowhere near as good as I feel I ought to be, as a woman-gamer.

What is interesting is that the level of anxiety that surrounds me playing multiplayer online battle arena (MOBA) games greatly exceeds anything else I have done: public speaking, presenting research, taking a math final... even wooing hot-shot investors. Although -- no surprise -- playing games is more fun, it is also the thing about which I have such serious performance anxiety and self-criticism.

Getting over it, baby steps

Really? This is what I look like?

I have attended several "impostor panels," panels and talks about impostor syndrome -- including at Grace Hopper Celebration for Women in Computing and locally at my university through the women in science, engineering, and technology group. Here are some of the steps in dealing with stereotype threat and impostor syndrome.

Recognize it. Just knowing that stereotype threat and impostor syndrome is there, looming, empowers you to reframe your experiences, both during the experience and after the fact. Recognize that your feelings, although genuine, are affected by societal pressures, and that these are things you can change.
Talk about it. Lots of other people have these feelings. How many other women feel like I feel about video games? I have no idea. But I know that lots of other women feel this way about being in computing, hard science, and math fields because I have talked to them about it. I have heard their stories and shared mine. And part of moving on is to get validation.
Help others. One of the ways found to counteract stereotype threat was to just say at the start of class that the threatened group is expected to (or is known to) perform as well as the other group. "Men and women score the same on this test." If you are a professor, teaching assistant, teacher, or just a friend, you can do this. One (male) player told me, "You play just as well as my other friends." And that was priceless.
Take criticism, and take praise. Criticism is meant to make you perform better. You could have solved that problem differently, better, or faster? Think about it, and move on. If someone offers praise -- you really blew everyone out of the water with that proof (or damage-dealing stun), take it at face value. This part is difficult, but you can start by saying "Thank you" rather than the self-insulting "Oh, it was nothing" while feeling that you did not deserve that victory. There is even a WikiHow on how to stop putting yourself down.

One final note for women: In online multiplayer video games, it helps to remember that more than half the time, everyone else thinks you are a 14-year-old boy anyway. Me? I like to act the part.

About you

Have you studied stereotype threat in women in video games? If so, I would love to hear about it. I have found only one proposed study on stereotype threat for women in gaming, and the rest seems to be anecdotal. How has your experience been?

I write like Jonathan Swift?!

2011-10-26T11:36:00.000-07:00

I Write Like, the website which analyses your writing and tells you which author your writing resembles most, analyzed my blog with the following result:

I write like
David Foster Wallace

I Write Like by Mémoires, journal software. Analyze your writing!

Next, I input a couple paragraphs from my most recent publication on file systems usability:

I write like
Jonathan Swift

I Write Like by Mémoires, journal software. Analyze your writing!

What's interesting is not necessarily the authors, but what this may mean. Is my academic writing hard to read and antiquated? Do I use unnecessary English anachronisms? I don't know.

But I do know that I Write Like analysed a professor-mentor's academic writing as David Foster Wallace. Her grant proposals read like my blog.

That's harrowing. By which I mean, that's distressing.

Why I'll never be a nurse

2011-09-23T15:00:00.000-07:00

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

2011-09-23T11:47:00.000-07:00

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.

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

2011-09-09T23:10:00.000-07:00

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 --

Gush!

"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.

Crying

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.

Complete

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!"

Postpartum

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.

Foreshadowing?

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?

Birth partners: Lend me your ears!

2011-09-06T10:40:00.000-07:00

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!

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

2011-09-02T12:31:00.000-07:00

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.

Negotiations

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.

Due

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.

Shocker

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.

My midwife failed me: How homebirth transfer affects mothers

2011-04-25T00:07:00.000-07:00

Homebirths account for just a small percentage of all births in the US: 0.59% of births happen at home. Interestingly, this number increased by 5% between 1990 and 2005, which we could call a surge in homebirths [1]!

Besides homebirths being more satisfying for women [7], one of the main reasons some women choose a planned homebirth over a hospital-based delivery is because both mothers and babies have better outcomes. The cesarean section rate in homebirths is around 4%, compared to over 30% nationwide [4]. Mothers have fewer interventions, including episiotomy (a surgical cut to open the vagina), and babies die less often [2].

There is no way to sugar-coat that. Babies born at home die less often -- because of the lack of unnecessary interventions. One meta-analysis found that the neonatal mortality rate tripled in planned homebirths versus hospital births, and attributed the better outcomes for babies to the decrease in interventions [2].

Not all mothers that plan to deliver at home end up doing so. For a variety of reasons, a transfer to a hospital may be necessary or preferable during or after childbirth. Sometimes the reason for transfer is maternal exhaustion -- labor takes a very long time and the mother is too tired to go on. Sometimes there are negative health signs with the baby -- heart rate decelerations, or meconium in the amniotic fluid. Rarely, the transfer is caused by something more grave. Usually, the decision to transfer from the home to the hospital rests on the midwife. In the US, the transfer rate is around 12.1% [4].

But how does a woman, who planned to deliver at home, who spent months preparing for her natural birth within the safety and comfort of her home, who anticipated an intimate experience, feel about a transfer to a hospital? Anecdotal evidence hints that something is missing from the birth experience. Does the mother blame herself for failing to deliver a baby at home? Does the blame later shift to her midwife, for letting her down? Is she grateful for being able to spend even part of her labor at home [6]?

We turn to science for an answer.

Is homebirth transfer traumatic?

Let's take a look at the Netherlands, where the homebirth rate is much higher than the US: In one study, over 38% of first-time moms and 67% of repeat mothers delivered at home (recall that the US average has risen to under 1%) [3]. For the first-time moms, 40% of the planned homebirths ended up transferring to the hospital at some point during birth or shortly thereafter; and 11% of repeat moms transferred to the hospital (compared to 12.1% of home-birthing mothers in the US, both first-time and otherwise). The Netherlands data is summarized in the table below.

	First-time mother	Repeat mother
Planned homebirth	38%	67%
Transfer to hospital	40%	11%

The women in this study rated their birth experience, their midwife, and their immediate postpartum days by marking agreement with specific adjectives on a five-point scale (where 1 is strongly agree and 5 is strongly disagree). The conclusion from this study?

Our research showed, contrary to expectations, that an unplanned transfer from a planned home birth to hospital has little influence on the experience of childbirth [3].

Let's look at Sweden.

In Sweden, homebirths are rare -- as rare as in the US -- that is, less than 0.1%. In Lindgren, et al.'s study [5], the homebirth transfer rate was 25% for first-time mothers -- that is, one in four women that plan a homebirth end up in the hospital (much better than the 40% rate in the Netherlands). The most common reasons women transfer to the hospital are "lack of progress" and (this was surprising to me) the midwife being unavailable for the mother during labor.

The exciting conclusion in Sweden:

Being transferred during a planned home birth negatively affects the birth experience [5].

Looking elsewhere, we find agreement:

Women who are referred to the hospital while planning for a home birth are less satisfied than women who planned to give birth in hospital and did. A referral has a greater negative impact on satisfaction for Dutch women [than for Belgian women] [7].

In fact, the Swedish study found that women really hated and resented their homebirth transfer experiences, as visualized (by me, from Lindgren's data) by the graphs shown below in Figure 1 and Figure 2. In these graphs, the blue line indicates a "very satisfied" response and the red line is anything less than "very satisfied." The thing to take away from these graphs is the area inside the red line. A large red area is bad. In the homebirth without transfer case, you can see that women were more likely to be "very satisfied" with all aspects of their birth (except for being in control -- but can you really control birth?). In the homebirth transfer case, women were more likely to be less than satisfied with everything except partner support and the midwife making the partner involved.

Figure 1. Satisfaction among Swedish women regarding their homebirth experience [5].


	Figure 2. Satisfaction among Swedish women that planned a homebirth but transferred to the hospital during or as a consequence of childbirth [5].

Homebirth: Forbidden fruit

Could it be, then, that in places where homebirth is rare, women place undue emphasis on the location of birth? Could it be that birthing at home becomes kind of a holy grail that women strive for? It is so rare in the US and Sweden that it is like a forbidden fruit. We hear and read so much about its beauty that we -- that is, those women that yearn for homebirth -- strive for it and are crushed when we do not get it.

Consider another birth outcome some women consider traumatic: the cesarean section. One thing that childbirth educators did to make the prevalence of the c-section more palatable and less scary is to demystify it. In childbirth education classes, c-section is presented as a possible birth outcome -- a real possibility. In a good prenatal education class, analgesia, surgical procedures, and postpartum recovery will be discussed in detail. When you think about it, this is a really good idea, because one in three people in the classroom will have this surgery, whether or not they planned for it.

It may be that one of the things that makes homebirth transfer an emotionally crushing outcome is that it is still an unknown evil. So why not demystify the homebirth transfer? Describe it in detail for women and their birth partners to take in: causes, procedures, outcomes. The Wiegers study made this interesting note:

It seems more important ... to reduce the fear of unplanned [homebirth to hospital] transfer, especially among nulliparas, than to advise women to choose a hospital birth in order to avoid such transfer [3].

Interesting because this is the only study that I found that did not result in negative emotions in the mothers resulting from homebirth transfer. Maybe in the Netherlands they drill the transfer as much as we (ought to) drill the c-section?

Lindgren had a different conclusion:

Treatments as well as organizational factors are considered to be obstacles for a positive birth experience when transfer is needed. Established links between the home birth setting and the hospital might enhance the opportunity for a positive birth experience irrespective of where the birth is completed [5].

In fact, in the Sweden study, one of the main reasons women were unhappy with the hospital setting was because everyone was so dang mean to them -- possibly for choosing a homebirth to begin with. They found that doctors -- obstetricians, general practice physicians -- simply do not understand what a midwife does in the home and why she should continue to be useful even after a transfer. Maybe the homebirth transfer education should start with the hospital.

Did my midwife fail me?

I do not know. But I do know that everywhere around the world where homebirth is rare, homebirth transfer to a hospital carries with it a negative weight. In the Sweden study, half of the women that underwent homebirth transfer were less than satisfied with their midwife's support, compared to over three-fourths (76%) of those that stayed home. Not surprising when you consider that the #2 reason for transfer is because the midwife simply could not come to the birth [5].

Conclusion

There are three ways to fix the problem of the negative affect of homebirth transfer.

Teach hospital staff about homebirth transfers. Drill it, demystify it. Emphasize that a transfer is not the mother's fault; it is not the midwife's fault. These things just happen.
Teach mothers that plan for homebirth about homebirth transfer. I mean, really drill it. It is a real possibility and a mother should know the routine. Drill it, demystify it. Encourage that a transfer is not her fault.
Encourage homebirths. There is reason to believe that, when the overall percentage of women that plan for a homebirth is large, a transfer to the hospital is no big deal -- possibly because the hospital staff know what to expect from a woman and her support team, and how to best help.

Given our surge in national homebirth rates (still under 1%, but we do our best), you would think we would be quick to implement these items.

References

[1] United Press International (2010). US Homebirths Few, But on the Rise. Retrieved 4/24/11.
[2] Wax JR, Lucas FL, Lamont M, et al. (2010) Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis. Am J Obstet Gynecol 2010;203:243.e1-8.

[3] T. A. Wiegers, J. van der Zee, and M. J. N. C. Keirse (2001). Transfer from Home to Hospital: What Is Its Effect on the Experience of Childbirth? Birth, 25 (1).
[4] A. Haas (2008), Homebirth After Cesarean. Midwifery Today.

[5] H.E. Lindgren, I.J. Rådestad, and I. M. Hildingsson (2011). Transfer in planned home births in Sweden – effects on the experience of birth: A nationwide population-based study. Elsevier 2011.
[6] J. Davies, E. Hey, W. Reid, G. Young (1996). Prospective regional study of planned home births. BMJ 1996.
[7] W. Christiaens, A. Gouwy and P. Bracke (2007). Does a referral from home to hospital affect satisfaction with childbirth? A cross-national comparison. BMC Health Services Research 2007.

Surprise birth during a doula interview!

2011-04-17T15:33:00.000-07:00

Hey! I thought when I received the friend request on Facebook. I haven't heard from Mia in years! I wonder what she's up to.

I scrolled over to her photos and found she was very, very pregnant. How lovely! I posted on her wall. Almost immediately she replied: Did I read that you are a birth doula?

We chatted over Skype a few days later. "Do you really want me at your birth?" I asked. She grinned into the webcam and gave the double thumbs up. We decided we would have our first prenatal visit on that Saturday, just five days later, when she would be at 38 1/2 weeks pregnant with her baby girl. We would discuss her preferences for the birth, I would meet her partner, Henry, and the three of us would read over my contract.

Saturday rolled around and I hopped on a train in the morning to go into the city to their central apartment, leaving my son in the care of my mother and my husband. I brought nothing with me but my positive attitude and a can of iced coffee. I looked out the window and thought about how exciting it was to be reconnecting with an old friend, and going to a doula interview.

My phone buzzed with a text message from Mia: "These contractions are different," she wrote -- not like the Braxton-Hicks contractions she had been feeling for the last several days. Different how? I texted back. She described them as achy, spreading from her belly into her back and hips. "Like menstrual cramps," she wrote.

Huh, I thought, How curious. I considered how she messaged me two nights ago saying she was filling her freezer with food, and later that she spent all morning cleaning and rearranging her apartment.

I arrived at the train station, where Mia was waiting beside her dusty, grey car, wearing a stretchy dress. She was just as I last saw her: very tall and very skinny, with curly dark hair and cute, small glasses, but with a basketball tucked in her sweater. I ran up and hugged her, scolding jovially: "Are you in labor?"

"Maybe!" she exclaimed.

This could last all night

We hopped in the car and tried to catch up while I drove. She rattled off directions. It was hard for both of us to conceal our excitement. Then she hesitated.

"Ah, a contraction," she said. "I'm going to try to talk through it, just to show that I can." And she continued her story about how she and Henry went to the movies the night before.

No problem, I thought. Early labor. This could last all night.

"So did you know?" I asked. "That you'd go into labor today?"

"Oh yeah," she said, "I knew. Henry didn't, but I knew."

In Henry's one-bedroom apartment that they shared, we got ready to go to breakfast. During contractions Mia would roll her eyes, take a long breath, and pace the living room. I texted my family: Mia in early labor. Maybe tonight, maybe tomorrow night. Staying here.

The three of us took a slow stroll to a nearby restaurant, on top of a beautiful, tall building with flowers and trees growing on the roof. Eastern drum-beats played over the speakers and I thought of belly-dancers with bells around their ankles. We were seated in low armchairs surrounded with pillows in front of a copper table. Mia, sitting on a towel just in case, ordered a hearty breakfast. By this time, during contractions, she would stop what she was doing and concentrate inwardly, breathing deeply with eyes shut loosely.

The waiter approached us with our food and looked concerned. After a contraction, he smiled and said, with a light Persian accent, "You aren't going to have the baby right here, are you?"

"No, no," Mia replied, smiling. "It will be a while."

With this public acknowledgement, suddenly, I became energized. Everything was tingly, exciting, colorful, happy. We were going to have a baby! Other patrons of the restaurant turned to us and smiled encouragingly; I beamed back. Henry beamed, touching Mia tenderly on the knee. We were supposed to discuss business, but it never happened: we were too excited that this was all happening!

We ate our breakfasts gaily. Every few minutes Mia would put her plate down, lean back in her low chair, and exhale. After the contraction, she would bring her plate back up to her belly and use it as a shelf.

On our walk back to the apartment, Mia sat during contractions on the benches we passed, but noted that walking felt better. However, as we approached home, she mentioned she would rather not be around other people. Aha! A clue about our labor progress: in active labor, women prefer to be in a safe place with fewer distractions and no strangers. There is a hormone released that can actually slow down or stop labor when women feel threatened. It is part of the fight-or-flight response.

Meanwhile, my husband was coming up by train to drop off my doula bag with some overnight necessities. With Mia and Henry's blessing, I parted ways for about 15 minutes as I ran to meet my husband half-way between the apartment and the train station.

When I returned, red suitcase in hand, to the apartment, Mia was on the phone, calling friends are relatives and checking in with her doctor, to let the hospital know we would be coming within the day. "Henry and I are in labor," she would say. Then: "I need to call you back." She would hang up the phone, breathe through a contraction, and call again. "It is hard to talk through those," she explained to the person on the other end.

I thought it would be a good time to talk about drugs in labor, because we never did that.

"Do you want to pick a safe-word?" I suggested. A safe-word is a secret word that we choose in advance that means I really want medical pain relief. "Sometimes, women may say they want drugs, but what they mean is that they want more support," I said. "Sometimes women want more support when they're scared, and they ask for drugs."

"No safe-word," Mia said. "I'm not scared. I just don't want to be in pain."

"There is a line between pain and suffering. Pain is expected, and it is good. But we don't want you to suffer."

Mia took a long shower. Then, Mia said she was tired. Still thinking there was plenty of time and that this was fairly early in the labor, I suggested she take a nap and mentioned -- you know, by the way -- that intercourse was likely to speed things along. Henry looked at me like I was crazy. Mia disappeared with Henry into the bedroom and I waited in the living room, listening for sounds of difficult labor and hearing none.

Undressed

About an hour later, Mia re-emerged, naked. I thought: The apartment is very hot. That is why she is naked. One midwife once said that you can tell how far along in labor a mother is by where the sheets are. If the sheets are pulled up to her chin, she is in early labor. If the sheets are at her waist, she is in active labor. If the sheets are missing, she is in the second (pushing) stage. We were certainly nowhere near the pushing stage, but the lack of clothing was a sure sign.

From here on, Mia's bowels moved every half hour and contractions were about five minutes apart, but some lasted only 30 seconds and some were longer. Playing it down, I said, "Your uterus is finding a nice pattern, and you are likely entering active labor." Turning to Henry, after a particularly long contraction (about a minute and a quarter) that required a lot more concentration, I added: "That is what active labor contractions look like. We want them to look like that." Mia leaned forward over the bathroom sink and danced slowly from foot to foot while I counted in rhythm with her dance.

Mia came out of the bathroom saying, "I am certainly in an altered state now." An altered perception of time is common in active labor.

I grinned, proud of our accomplishment. "Do you know what time it is?"

Mia thought. "Maybe five?"

Henry looked at his phone. "Six," he said.

In our postpartum meeting, Mia pointed out that it was not just an altered perception of time, but an altered state of consciousness that she felt at this point. "In one of our classes," she said, "we were told about early labor task. We were told about a woman (an author, I think) who monitored her state of consciousness for change between early and active labor by baking cakes. Making a cake requires one to read a recipe and measure amounts carefully. In active labor, it is not possible to do anything accurately. The will and perhaps even the ability to focus on a multi-step task just goes away."

What about massage, stroking, and other physical comfort measures in labor? Twice, Henry tried to stroke her on the shoulder, or would touch her curly hair in a loving gesture. Mia's response was unilateral: "No touching."

Smiling, I turned to concerned Henry and said, when Mia was out of earshot: "Totally normal."

A few hours passed in this way: We counted through contractions: ten counts up, nine counts down. Mia changed positions from the toilet to slow-dancing with Henry to leaning over a chair to leaning back on the coffee table from an ottoman. She looked so beautiful -- her round belly illuminated by the sunlight filtering through the closed shades, as she rocked back and forth or danced from foot to foot. Her head rolled on loose shoulders. She visualized waves breaking over her body.

With each contraction, Mia announced: "Start!" Henry dutifully pressed the start button on his contraction logger app on his mobile phone. Then, she would breathe and roll her eyes and dance, exhaling the contraction. "Stop," she would announce. Henry would mark the end of the contraction. In my opinion, the contraction app was a blessing: it kept Henry busy and made him feel like he was performing an important role in labor. During contractions, his focus was on Mia, but between, he could mentally calculate averages and cross-reference them with his knowledge of labor.

On the toilet, mucus and water came out. "I think this is my mucus plug?" Mia said, examining the toilet paper. "Sure," I nodded. But we were far past the mucus plug, even though when I checked Henry's meticulous log, I saw that contractions were 4 minutes apart but rarely over a minute long. In fact, most were between 40 and 60 seconds long. When we talked about this discrepancy postpartum, Mia explained: she did not announce the beginning of the contraction, but when the real discomfort began; similarly, she announced when the discomfort stopped, not when the tightness eased. Henry and I should have mentally added 10 to 20 seconds to each measurement!

Surprise at the hospital

Henry called the hospital. During the phone call, I took the phone from Henry during a contraction and talked to the nurse.

"First contraction happened at eleven this morning," I said.

"Has she been keeping hydrated? Is she resting?" the nurse asked.

"Yes," I replied, "a sip of water after every contraction. She had a good breakfast and a nap in early labor. We've been in active labor for, hmm, maybe an hour?" Even as those words escaped my lips I knew it had been longer than an hour. But I did not offer a correction.

There was a pause. Then: "OK, you'd better come in."

"We may be a while," I said as I looked at Mia, totally naked, draped over Henry.

"That's OK," the nurse replied. "We will have a room for you."

And so we started getting things together. The car was already packed; we just needed last-minute things: camera, charger, phone, charger, Mia's earrings that she removed earlier -- oh, and clothes for Mia. Because she was still naked.

"I'll wear my grey stretchy dress," she said. "It is really stretchy."

She waited patiently in the bathroom while Henry rifled through her drawers, bringing grey things that weren't dresses or dresses that weren't grey, until finally, he found the right dress. Mia started pulling it on. I tried to smooth a wrinkle. "No touching!"

She put on panties with a maxi-pad, green slippers, and waddled to the door. We went downstairs to the parking garage and waited by the car for a contraction to pass.

"Henry, sit behind me; Mia in the front; I drive," I said. "Go! Go! Go!"

Mia spoke directions in the same voice as this morning, but a little more distant. Outside, the sun was setting over the city in a beautiful red, pink, and purple sunset. A contraction started.

"It's OK to pull over," Mia said. "Just double park." I did that and counted. Up to ten, down to one. We continued, pulling over twice more.

Mia said: "I will want an epidural when we get there. I have been enduring this long enough."

"Let's see where we're at in the labor," I suggested. "After they check you, we'll see. OK?"

Arriving, I helped Mia out of the car, and let Henry take her inside while I parked in the garage. We had considered parking all together and walking in ("the walk would be good for you," I said) but it did not seem possible anymore. How far along were we? I had no idea. I gathered our things (three bags) and ran to the main hospital entrance where I dropped off Henry and Mia. To my chagrin, it was closed -- that entrance closes at 8 o'clock, and it was exactly that. A pizza guy was standing outside the main entrance as well, looking confused. I greeted him, turned, and ran up the hill to the emergency entrance. Her last contraction, Mia puffed at the peak and then mentioned some pressure. Pressure means pushing. Could we really be that far along? I imagined her and Henry walking toward the entrance, stopping for a contraction, and the baby suddenly being born, right there on the sidewalk.

I signed in to the visitor log, with the pizza guy right behind me. The emergency waiting room perked up with the smell. I ran down the hall, waited hours for the elevator, and finally arrived at Labor and Delivery, where I had to sign in again. I saw that Mia and Henry signed in just five minutes before me -- good sign, it means the baby was not born on the sidewalk or in the corridor as I feared.

Mia was in the tiny triage room with Henry and a nurse, on the bed, still pregnant, with the fetal monitor strapped to her belly as the nurse tried to find the heart beat. For a while, there was nothing. I held my breath. Where was the baby? Was she OK? Then, she found her: low. She breathed through another contraction as I counted. At each contraction, the nurse paused what she was doing and waited. How nice, I thought. A nurse that knows how to let a woman labor.

"Have your waters broken?" asked the nurse between contractions.

"I think so," said Mia. "There was a trickle."

The nurse explained that there does not have to be a gush: sometimes when the waters break on top, there can be a trickle as they leak around the amniotic sac and out the cervix. When they break on the bottom, you get a gush; then, the baby's head presses against the cervix and stops the flow.

The nurse said, "I'll let the doctor check you once we get you a room, since your waters may have broken. I don't want to increase the chance of infection."

After the next contraction (she puffed at the peak again, quick in-out-in-out breaths), she turned to me and Henry and said, "Pressure again."

I looked at the nurse, who did not seem to hear. "Mia says there was some pressure," I said, emphasizing the word. "Pressure."

"Perhaps I had better check you now," she said. All eyes turned to her as her hand disappeared between Mia's legs and the blanket. Her eyes widened.

Grinning, she said: "You're not going to believe this. Guess! Guess how far you are!"

Mentally, I guessed as from under the sheets escaped the smell of transition. It is a peculiar, memorable smell.

Getting no reply, the nurse continued: "You're a nine. Nine and a half! There's just a little lip. Zero station, meaning the baby's head is right up against your public bone." Holy crap! Henry's eyes widened. I had no idea. Mia's contractions were short, she had never vocalized, and she looked so natural and calm!

"Can I have an epidural now?" Mia asked, not amused.

"Honey, there's no need," said the nurse. "Look at you! You are doing so well! By the time we get the doctor in here, and the epidural to take full effect," she gestured a circle with her arm, "the baby will be born!"

I suggested, "The contractions aren't going to get any worse."

The nurse continued: "That's right, and it will feel so good to push against all that pressure."

One more contraction. Breathing, puffing, as the nurse struggled to find an empty room for us. We were not even in the computer. Nurses started coming in and out, introducing themselves to Mia in loud, even voices. One nurse started a hep-lock (IV with nothing going into it). One checked again: Mia was complete.

But the orders were to puff, not push.

Eventually, we were all transported into the operating room because, unbelievably, that was the only room available where we could deliver a baby. Henry and I dressed in white paper jump-suits and white fluffy shower-caps and shoe-covers, and Mia was instructed to hop (hop?!) from the triage room bed to the operating room birthing bed. A tall order for a lady pushing out a baby, but she did it with grace.

Birth

As soon as we arrived in the operating room -- large, round lights overhead and little carts of equipment everywhere -- I asked: "Can we push now?" The nurses beamed and nodded. "You sure can!" I turned to Mia.

Without instruction, without anyone yelling at her to push, without anyone coaching her to make a C with her spine and pull her knees to her chest and hold her breath and count to ten and wait for a contraction, Mia pushed in a raised position on the hospital bed, hands on her thighs. And those were some mighty pushes.

Her water finally broke in earnest, spraying eight feet down the bed and narrowly missing the nurse. We laughed; a lock of the baby's hair was seen.

To Henry, I said: "Want to see?" He shook his head, but after a little more coaxing, he glanced, white knuckles hanging on with all their might to the side of the hospital bed. He looked pale, and stroked the pillow above Mia's head with his thumb, looking gently at her forehead.

"She has curly black hair, just like you," I said to Mia. "And it's long. Reach down and touch her." With long, slender fingers, Mia stroked the top of her baby's head gently, until another contraction came. The head was at the perineum.

"You have to get past this," I said as Mia squirmed her hips side to side. "You have to go through it." I hope I sounded brave. I really wanted to sound brave. It is hard to tell a woman to do something clearly painful, something contrary to what the body says: to push into the pain and the burning on the perineum. Henry clung to the bed; a nurse poured mineral oil on the baby's head to lubricate the exit.

In two more contractions, just an hour and a half after our arrival at the hospital, baby Cathy was born in the operating room, in what was one of two natural births in the hospital that day (usually they have one every other day or so). Cathy cried on Mia's chest as nurses rubbed her pink body; pale, Henry cut the cord, signifying the entrance into the world of his baby girl. Against Mia's skin, baby Cathy was visibly calmer, though still bewildered. Mia shielded Cathy's eyes from the harsh operating room lights and cooed: "I know, baby, I know -- it's so bright in here."

Postpartum

In the recovery room (which was actually a labor room -- all of the recovery rooms were still busy for the next hour or so), Mia breastfed her newborn for an uninterrupted two hours. The nurses waited until Cathy was full to do the usual weights and measurements.

While breastfeeding, Mia turned to Henry and me with glistening, happy, tired eyes and said, with her mouth watering: "Oh, man -- we should order a pizza. A deep dish pizza. Doesn't that sound so good?"

Conclusion

That was the best doula interview I had ever had.

Should I come to my partner's first prenatal visit?

2011-03-27T22:35:00.000-07:00

Yes, unless it is logistically impossible.

Being newly pregnant can be an emotional experience, especially if you have (or she has) been trying to get pregnant for a long time, and even more so if you have been trying not to. You should be there to support if a shoulder is needed, encourage if a smile is needed, and just be present if your company is needed.

Let's assume for the rest of this post that the pregnancy is a welcome event.

Beyond what she, the mother, needs, the first prenatal checkup is usually where the pregnancy is confirmed, and you will hear the baby's heart beat for the first time. This is really neat, and if nothing else, you should be there for this moment: the moment you receive proof that inside this lovely woman is another life.

This is also a good time to interview your midwife or doctor to make sure you get along on a very basic level. Do you "gibe?" Do you feel good about this person? Forget the day of delivery -- in a hospital environment, it is a toss-up whether or not this person will attend the actual birth -- what matters now is that you will spend quite a bit of time together.

Taking a typical low-risk prenatal visit with an obstetrician (duration of about 15 minutes) and the timeline of maternity care outlined by Drs. Sears, assuming the first prenatal visit is at 8 weeks gestation as noted by BabyCenter (not unlikely, as your missed period is at 6 weeks), you will spend approximately 2 3/4 hours locked in a room with this midwife or obstetrician. And that is a conservative estimate.

Here's the math:
One visit per month from weeks 8 to 28 = 5 visits
One visit per 2 weeks for 8 weeks (weeks 28 through 36) = 2 visits
One visit per week until born (weeks 36 to, say, 40, which is average) = 4 visits
Total visits = 11
Visit length is 15 minutes each, times 11 visits = 161 minutes = 2 hours, 41 minutes

In conclusion, yes, take the time off of work and join your partner on her first prenatal visit. Yes, go -- be supportive, be present, and be positive.

Amendment

A note about the case of miscarriage: If you attended the ultrasound to confirm the pregnancy and see the heartbeat, you should also attend the ultrasound to confirm the miscarriage. Remember that you are in this together. Because it is "we're pregnant," (not "she's pregnant") then it is also "we miscarried." She did not miscarry alone. When you attend the latter, more difficult, ultrasound with her, it will help her see that.

A very short birth: Emergency Caesarean and doula support

2011-03-03T15:09:00.000-08:00

What follows is my account of an emergency C-section birth, from the perspective of a support person. This birth changed my perspective as a doula.

Clay and Erin are the perfect young couple. At our first meeting, they hugged and touched and giggled, rubbing Erin's round belly and kissing each other sweetly. He was a military man with a hint of a southern drawl; she was a fair-skinned, red-haired maiden glowing in her pregnancy and reminding me of Loreena McKennit earth-mother songs. In her belly incubated baby Amber, soft and warm, caressed from all sides by her mother's lovely warmth.

The morning of baby Amber's birth, Erin went to her scheduled prenatal appointment and was delightfully surprised (yet slightly apprehensive) to find that she was 3cm dilated. "Today or tomorrow," Dr. Draper said, smoothing his grey moustache.

At 5 that evening, Erin called and told me of her first contractions. "They feel different," she said, comparing them to Braxton-Hicks contractions in her excited, fluttery voice. We checked in again at 7, when the contractions had suddenly intensified. I suggested keeping hydrated, taking a shower, or taking a walk. I remembered back to another recent birth in which the early labor contractions suddenly got intense, and how terrified I was that I was missing active labor. But when we arrived at the hospital, we were just at 3cm. I know that every mother is different, and every birth is different

At 8pm Clay called.

"We are thinking of going to the hospital," he said, and confessed that Erin was vomiting profusely with and through every contraction. They were having a hard time keeping on top of them.

"Can you wait for me to come?" I asked. "Help Erin take a shower or a bath. I will be at your house in an hour."

"I don't know," he said. "I'll call you back."

I packed my bags. Five minutes, ten, fifteen went by as I sat by the door with my bags. Suddenly, I knew that they had gone to the hospital. I left. Fifteen minutes on the road before I got a text message from Clay: "Come." They were at the hospital.

Terb-ulent contractions

I arrived at 9:20 to find Erin in a gown in the bed, monitored. Contractions were light and infrequent. I talked with Clay and Erin until the nurse came. She said Erin was between 3 and 4cm dilated, 90% effaced, at +1 station, with no change from admittance an hour prior. She was administered terbutaline, an injection just under the skin (usually in the arm), to stop labor.

Of course, as soon as I got home, I looked this up. Terbutaline, or terb, for short, is frequently used to stop preterm labor, but its use here, as a labor inhibitor, is controversial because controlled studies are lacking. In 1997, the Food and Drug Administration (FDA) wrote:

In the absence of data establishing the effectiveness and safety of the drug/device, FDA is alerting practitioners, home health care agencies, insurance carriers and others that continuous subcutaneous administration of terbutaline sulfate has not been demonstrated to be effective and is potentially dangerous.

In this case, it was not a continuous dose but an intermittent one, and it was not for preterm labor but for a full-term baby.

I did not fully understand the reason for administering terb until I had a chance to glance over the charts that the nurse collected from the contractions and baby's heart beat. With and after every contraction, the baby's heart rate plummeted. Not just a little. A lot. I did not know this until much, much later.

By 10:15pm, contractions had picked back up with terbutaline wearing off. And, as before, Erin vomited violently through every contraction. Clay held a bucket by the bed; the nurse and I took turns emptying it in the sink. There was exactly enough time to clean the bucket and get it back to the bed before another contraction required its assistance.

But the baby's heart rate was again decelerating with each contraction. The nurse started the oxygen mask flowing and called the doctor.

I suggested some position changes. We tried the hands and knees position on the bed. Erin hated it... but over the next two contractions, the heart rate deceleration showed a marked improvement.

Fluid around the cord

At 10:30, just fifteen minutes after our position changes and oxygen mask, Dr. Draper arrived in a shirt and tie under a white gown. Barely greeting the couple and not glancing at me, he looked at the charts as the nurse caught him up.

"Yes, I see that," he murmured to the paper trail of contraction bumps and baby dips. He turned to the nurse. "Who is the anaesthesiologist on call?" he asked as my heart sank. My heart sank and my blood pressure rose and my face burned.

I glared at Dr. Draper with all my might. I glared at him as strongly as one woman could glare at a man. I glared at him and shot little lightning bolts from my eyes as I sat nearby Erin's bed, and as I watched her glance sweetly, sadly, timidly, frightenedly at Clay. I glared because I knew that with just a few more minutes, with just a few more position changes, with just a few more attempts we could fix this thing. We could have our birth.

Dr. Draper turned to Erin and Clay and pushed his glasses up on his nose.

"Fetal intolerance to labor," he said. "I can prove it to you," he added as he asked for a portable ultrasound machine. He called up on the black and white display a blurry image of some moving black and white bits. Erin had a contraction and started puking. Clay looked at her face and at the bucket and at the monitor and at her face.

"You see that there?" Dr. Draper said to us. "See, that's the umbilical cord. That's the contraction, and here it's being compressed. There is no fluid around the cord." As the contraction ended, he pushed aside the machine and waited to have Erin's undivided attention.

"We need to get the baby out now. You know how I know? Because I've seen it before. I have seen this a hundred times before. I have made this mistake before. If we wait, the baby will not do well. We are so early in labor, and already the baby is not handling it well. We cannot wait. I have seen this before." Erin nodded throughout and agreed that whatever is safer for her baby she is willing to do.

With my hands folded and my voice calm, I turned to Erin and Clay and asked, quietly: "Do you have any questions?" Erin and Clay shook their heads.

"May I be in the OR with them?" I asked, ready for a fight.

"Yes," said Dr. Draper and walked out of the room with some mumbled instructions to the nurses. He called the c-section at 10:40pm.

The room started bustling. One nurse gave Erin another shot of terb just as a contraction was starting. Clay readied the bucket. Another nurse brought an OR kit -- hair net, gown, and mask -- and placed it on the bed for Clay. "One more, please," I said; the nurse nodded and left, reappearing with another set. Erin and Clay both received arm bands and a tiny one was prepared for the infant. Other infant items materialized: a baby warmer, a bassinet. As this was happening, I went to the nurse and asked:

"What is Dr. Draper's c-section rate?"

"Oh, I don't know," she said. "Probably like the rest of the hospital. Thirty-three percent." I was interested to know this because this particular hospital is privately-owned and does not publish its birth statistics. The c-section rate was at the US average. Knowing this added fuel to my already-burning fire and I seethed, confident in my opinion that the doctor had made a hasty call.

"Do you guys do VBAC?" I asked, meaning vaginal birth after c-section, an option for many women. I kept thinking about Erin's beautiful round belly.

"No, we can't do VBAC here," she replied sadly.

Erin was wheeled to the preparation room; Clay and I were escorted to the recovery room to wait. This empty, lifeless room had two hospital beds, sterile floors, and a chilly atmosphere. We dressed in our yellow hospital gowns.

"I guess it's time to tell the folks," Clay said after several minutes of silence, and began sending text messages on his phone.

We tried to play guess-the-time-of-birth, but the mood was somber.

Birth

Finally, the nurse called us in to the operating room. Erin was on the table with bright lights beaming down on her tired, worried face. Clay's touch was clearly soothing, comforting. I stood nearby with the camera and took pictures, explaining what I saw. I was careful not to take any photos of the incision, as the doctor requested.

"Now he is cutting the fat layer," I said.

The nurse exclaimed: "Not that you have hardly any fat layer at all!"

"Now he is opening the uterus. Now he is breaking the bag of waters." The suction device picked up dark, chunky fluid, stained with meconium, and transported it through a clear plastic tube to a receptacle. "Breathe through this part," I suggested, remembering the previous c-section that I attended, in which the doctor wrestled the baby out over the course of what seemed like an hour. "You'll feel some tugging. Now he is lifting the baby's head. The head is born. Now the rest of the body." There was not as much tugging as I anticipated as the baby entered the world, a dozen hands holding her up.

Dr. Draper delivers baby Amber as nurses stand by.
Photo by PhDoula.

Time of birth: 11:26pm. The nurses took the baby to a warming station and vigorous rubbing began. Unlike the previous c-section that I had seen, Clay was not allowed to go to the baby. Clay and I watched both Erin and Amber. Every few minutes, I would ask: "Can Clay go to the baby now?" but the answer was always no.

Dr. Draper talked as he operated. "Yes. I have seen this before. The cord was around the baby's head, and it was being compressed between the head and the uterus. It's called a nuchal cord."

After cleaning the area thoroughly, Dr. Draper continued: "It used to be cool to have 10, 15 years of experience. But I have been doing this for 25 years, and it makes me sound old."

I asked: "How many babies have you delivered?"

Dr. Draper said, "Thousands."

Choosing his scythe-shaped needle and clear thread, which reminded me of liquid cat whiskers, Dr. Draper began sewing. "Hmm, yes, I think I can sew this together in just one layer. Look at that. It just lines up together perfectly."

Shocked, I asked: "One layer? Is that safe?"

He replied in the same pensive tone: "Yes, in this case it is."

I paused. "Can Erin have a VBAC after this kind of stitching?"

"Yes, I don't see why not."

"But you don't do VBAC."

"No, we can't do VBAC here at this hospital. But I can give a referral to someone who does."

Afterwards, I learned that the two- versus one-layer stitching debate was a sore spot for many women. The debate goes as follows. One study (Bujold) found that single-layer stitching (discussion, editorial [PDF]) showed an increase in cases of uterine rupture in VBAC patients over two-layer stitching. However, the study had two serious flaws. First, the hospital staff was not as familiar with doing the two-layer stitching as single-layer stitching (so expertise was an issue). Second, the materials used to do the closure were not as strong as we have today (so equipment was an issue). Furthermore, there is good evidence that, when the fibers of the uterus line up well (as was the case here), single-layer stitching is just as good as two-layer stitching, in that it is strong, it has good structural integrity, and it is unwilling to be compromised under stress (e.g., through a subsequent trial of labor). Although some doctors simply will not even attempt VBAC with single-layer stitching, others will. Unfortunately, much of it depends on the doctor and on his or her insurance carrier.

The nurses brought a loosely-swaddled bundle to Clay. "Congratulations," they whispered, as they handed baby Amber to him. Clay held her like a freshly-baked loaf of bread, typical of the new father, and stooped low so that Erin could also see her sweet newborn face. They gazed together into her sleepy face with misty eyes, huge smiles, and little kisses.

After the stitching was over, Erin was bumped from the OR bed to the regular bed, and was wheeled to the recovery room where Clay and I had paced the confines of this sterile enclosure just an hour earlier. The nurses took baby Amber from Clay's hesitant arms to the nursery.

After a few minutes in the recovery room: "Does the baby have a name?" the nursery nurse, in charge of the infants, asked as she entered the room.

"Yes -- Amber," Erin replied.

"We need to keep Amber for a few minutes in the baby warmer. She is cold."

While we waited, we talked about the baby and how strange it was not to be pregnant anymore. Erin and Clay talked about which family to tell, whom to call. We examined in great detail every single dial and switch on the walls.

Every time the nurse came in, I asked: "Can Clay go to the baby?" or "Can Erin have the baby now?" or "Is the baby coming soon?" Twice, I sent Clay to go find the nursery and look at the baby through the window. Both times, he reported back that the baby looked fine.

It was clear that my job had become the nagger. I nagged during the surgery, and I was nagging now.

Finally they brought the baby.

Breastfeeding

As baby Amber was wheeled into the room, I had the impression I was watching a wedding. Erin and Clay looked at the baby, and I looked at the parents looking at the baby. Their faces expressed unbounded love and devotion, the kind of eternity people everywhere seek but do not know where to find. Their arms reached out to this new life.

He handed her to Erin.

"Oh, my little bird," Erin cooed, her eyes filling with tears.

I sat off to the side and snapped photos of the new family. In a while, Amber began to open her mouth wide and lick Erin's shirt: clear signs of interest in nursing. Swooning, I took more photos.

"Yo, doula," Clay said, "get over here." We laughed as I helped position Amber on Erin's chest. This was not an easy task given that Erin was completely numb below the ribs.

In the wee hours of the morning, Erin, Clay, and Amber were sleepily settled in their room, and I left.

Conclusion

We all go into births with some prejudices, whether or not we know about them. For some doulas, it is the idea that the epidural is the root of all evil; some doulas see birth as a magical gathering of rainbows and unicorns as a baby emerges perfectly into the world. Students of Ina May describe contractions as "rushes" so that the mother imagines them as energy rather than pain. For me, it was a distrust of medical doctors and especially their reasons for conducting c-sections.

At every step of the way, mentally, I challenged Dr. Draper, distrusting his reasoning and his methods, because doctors are prone to disregard the mother and treat only the condition. Because doctors hate to wait for a birth to come around on its own. Because vaginal birth is inconvenient and c-sections are faster. I challenged him when he made the call for a c-section; I distrusted the size of his incision; I questioned his choice of suturing method (and what an expert I am, right?); I frowned at the separation time between mother and baby.

When I went home after Amber's birth, I researched all of the things Dr. Draper said, and read a great deal. I worried about Erin and Clay: were they upset over this turn of events? Were they unhappy with their c-section? I had no idea, but other reading I had done (e.g., Pushed, Woman in the Body) suggested that women frequently have negative affect after an unscheduled c-section. In my research I was both convinced in the doctor's expertise and embarrassed at my emotional reaction to the events of the birth. So then in a sort of apology, I sent Erin and Clay this e-mail:

Congratulations on your baby girl!!!! Amber is so small and sweet. :-)

I just want to follow up with you and make sure you know that you and Clay totally made the right call. In fact, it wasn't your decision to make at all: Late deceleration is a definite cause for alarm, and persistent late deceleration at 3-4cm is a very good reason for a C-section birth. Amber wasn't doing well with labor, and didn't have enough oxygen in reserve to make it through the contraction. During a contraction, there was a normal decrease in the amount of oxygen exchanged between you and Amber, but she didn't have enough oxygen stored up to make it through each contraction.

Please don't feel sad; you did the right thing, and you had the right birth.

You and Clay were rockstars during the labor and during Amber's birth; you were both doing so well! You are an amazing and powerful birth-woman.

When we met for a postpartum meeting, Erin and Clay confided that they know they did the right thing, and there was no doubt in their minds. There were no hard feelings between them and their birth.

I was relieved.

This birth changed me as a doula. I became a better listener, and a better question-asker. I became more patient and more humble.

Should we go into interventions blindly? No. But we should be prepared for everything... and we should ask questions until we are satisfied with the answer; until we know, without a doubt, that we are doing the right thing.

An amazing Facebook birth

2011-02-27T13:14:00.000-08:00

This post is about Amy, a mom that recently had a baby while updating her friends on her 48-hour labor progress in real-time. As any mom that has gone through labor knows, this is no easy task! I commend Amy on her unique labor coping strategy of Facebook-ing while in labor.

About Amy

Amy and I go way back: We first met in middle school and went though tenth grade together, at which point my family and I moved across the US. Though we have kept in touch, our closeness and level of intimate knowledge of one-another could not have been possible without Facebook.

I found out that Amy was pregnant with her third child when she posted an update saying her first prenatal appointment was coming up soon.... at 38 weeks. Difficult financial times meant an unfortunate lack of health insurance, which prevented her from seeking prenatal care until fairly late in the pregnancy. Luckily, all was well with her and her baby. The baby was growing happily and Amy had no risk factors for things like gestational diabetes or pre-eclampsia. (However, over the next few weeks and prenatal appointments, the doctor was increasingly antsy to get the baby out -- threatening induction and c-section. My opinion? His reasoning was that the baby would be better off in his care than in the womb of a woman that would forego prenatal care.)

Nine days before Amy's due date (T-9), she mentions how difficult it is to be so pregnant:

Well this baby should be due anytime between now and 3 1/2 weeks from now... Wonder when he will want to come. Hard to roll over in bed!

Amy and I talked over Facebook; she told me this is likely her last baby, and her priority for her birth experience is to birth naturally, and especially without Pitocin, a synthetic oxytocin used to speed up labor or increase the strength of labor contractions. Her second baby was induced with Pitocin, and she had a difficult time with the labor.

Do you have a doula?

Of course, I asked if Amy had hired a doula.

"No," she replied. "Isn't it kind of late? I mean, I am almost 39 weeks along." Then: "Also, I don't think we can afford a doula."

Will you be my friend's doula?

That night I sent out an e-mail to a volunteer doula organization mailing list asking if anyone in her area would be willing to consider a volunteer birth, due between now and three weeks from now. The next day, I got an e-mail back with the name of a doula, Joanne, residing an hour and a half away from Amy -- which I immediately forwarded along. Amy called her. Joanne said yes.

Joanne explained that there were so few women in her general geographic area that a) wanted a natural birth, b) knew what a doula was, and c) were considering hiring one. Because of this, she was having a hard time meeting the requirements for the number of births attended, for certification through her organization.

Five days before Amy's due date (T-5), Amy feels large, sore, but excited about Joanne:

Feel rested, sore, and still quite preggo. Meeting with a doula in training today. Should be interesting - hopefully she'll be able to help me get the natural birth I want and avoid ALL unnecessary interventions.

Woot I gots me a doula!

Ug. Up at midnight with HORRIBLE heartburn even after 4 chewable heartburn tablets!! I thought heartburn was supposed to ease up when the baby was low but I guess mine likes breaking the rules.

Amy's due date came and went. The waiting game set in. Amy's status updates on Facebook became progressively impatient.

Pre-labor

For Amy, labor started slowly, over the course of about two weeks. In the days before Amy's due date, she mentioned light cramping that would eventually lead to contractions that would open her cervix. Her husband, Bill, noticed that the baby had dropped significantly,.

(T-3) Well I could be wrong, but I feel pretty sure that I'm now in prodromal labor. For those not aware of what that means, that's early labor. But no need to get excited. If I'm right it could still be days away. With my first, I had prodromal labor a week before she was born.

(T-1) Well when I took a bath this morning I felt like the baby wasn't as high. Bill confirmed, I didn't look as "pooched" as I have been so I'm assuming the baby has dropped. And I feel very very very tired. Standing on my feet more than a few minutes is exhausting.

(T-1) Off to bed. Baby is still cooking but he definitely is lower. And my blood sugar has been awesome even though I haven't changed anything. 115 or less 2 hours after eating every time. Go figure.

On Amy's due date (T+0), Amy laments waddling:

I am Pengo, the amazing pregnant penguin. At least that's how I feel when I walk... *waddle waddle waddle*. I don't remember waddling quite this much before lol! Then again, this baby is low and has been for some time, so maybe that's why.

The day after Amy's due date (T+1), life goes on:

Well the baby didn't move quite as much last night as in several nights past. Still moving, but not so active. Could mean one of two things, and I'm leaning towards the positive - which is that he's resting for the big day. Got a prenatal today anyways and they'll do a non stress test.

Two days past the due date (T+2), Amy mentions how low the baby is:

The waiting game begins. Last night when Bill and I were walking around the pharmacy, I could feel the baby pressing down as I walked. I know it's going to be very soon.

Four days past the due date (T+4), the baby still has not come, and Amy's stress level is rising:

Getting mixed reviews on whether stress induces or hinders labor. Either way, trying to chillax.

Twelve days past the due date -- that's a week and 5 days! -- Amy updates her friends and assures them that there have been no babies born (T+12):

Ok just posting an update because apparently if I don't people worry. :). Still preggo but I think the cramping may be getting regular. Should be soon!

Early labor

On the thirteenth day after her due date (T+13), the real early labor contractions came. They were light, and Amy did the right thing: relaxed, ate, drank, and continued her positive attitude.

9:39pm
Been feeling some contractions tonight, close enough together to make me wonder. So I'm up, eating something, watching some tv, keeping hydrated for a bit, to see if it progresses to anything further, or if it's just false labor and my high hopes for baby due on T+14 lol. Will keep this updated.

11:49pm
Well they seem to be regular contractions at least. About every 20-30 minutes, just not near strong enough yet. Regular is good. Going to stay up a bit longer then get some rest. Could just be a T+14 baby yet!

The next morning (T+14), Amy finds the contractions have not developed a pattern (meaning that, if this were labor -- which it was -- it is still early labor):

6:20am
Baby is still moving and I believe I'm still feeling contractions. Half asleep right now seeing Bill off to work but have felt like two since I woke up. I can only assume they kept going overnight, they're just not strong enough to wake me up or keep me up. Would be funny if he was born at 2 in the afternoon today... You know... 14:00 military time. T+14. Ok anyways we'll see!

By the evening (T+14) the contractions were still present, but not consistent. By now it was clear that this was the real thing: labor. Her husband Bill, Amy, and I all joked on her status messages.

5:51pm
Contractions are now averaging about 10-15 minutes apart. May be tonight, maybe tomorrow... Time will tell!

Me 8:21pm
Let's see if you post all the way through labor. E.g., "Pushing. Baby at +2. Crowning eminent."

8:23pm
LOL I don't think my pain tolerance is quite that high lol. Right now I'm at the pain level of noticeable, I breathe through it and manage. I seem to remember it was like this a day before my first was born... The night I slept in the bath tub for 3 hours because I couldn't get rest any other way lol

Bill 10:04pm
Don't tempt her. She'll be in the middle of pushing and posting at the same time. You watch.

Me 10:33pm
I subscribe to this thread. Let the labor/posting commence! ;)

10:35pm
Lol just painful contractions at the moment ten min apart. Give or take. I'd rate it at about 5 right now. Well at least as far as I can remember. It was 6 years ago lol.

At this point, I thought I should ask about her doula. Given that Joanne lives an hour and a half away, she should probably have been notified by now. A surprising (for the readers) turn of events is unfolded. But Amy still kept her positive attitude.

Me 10:36pm
Have you called your doula???

10:38pm
Turns out she won't be able to make it. She told me last night. She is now pregnant herself and has bad morning sickness. Sucks but it's ok. I'm just thrilled I went into labor naturally.

Me 11:10pm
Doesn't she have a back-up? :(

11:11pm
I have no idea. It was free and she was in training so I guess I can't complain too much.

That evening (still T+14), Amy turns in for the night as she normally does.

11:24pm
Going to try and get some sleep. We'll see how that goes.

Active labor

On the 15th day after her due date (Amy is now 2 weeks and one day late) (T+15), in the wee hours of the morning, Amy is awakened by contractions:

3:48am
Contractions are waking me up. I'm saying they're pain level 6 or 7 right now. I'm not quite ready to rush off to the hospital just yet though.

Nearly three hours pass; Amy decides to go to the hospital. There, she is admitted, and is delighted to discover she is at 5cm -- active labor. The current thinking is that hospitals will not admit women under 3cm dilation because the risk of unnecessary (and costly) interventions increases the smaller the dilation upon admittance.

6:17am
Going to the hospital now. Contractions are pain level 8 lasting a minute or longer and 5 min avg in between

6:24am
I can only go based on my experience with my first but with her they never got closer than 8 min or so apart during transitive labor. The pain feels similar now just they're closer together. Each pregnancy is different I guess. We'll see how accurate my self assessment is in like 40 minutes

7:39am
5 cm dilated

7:41am
My muscles are so tired already

A mere two hours later, Amy enters transition. This is fantastic progress, and she should be proud (though, at the time, I am sure pride was the last feeling on her emotion stack).

9:51am
In [transition] phase now. 7 cm.

Half an hour later, during what women frequently consider the most intense part of labor, Amy posts a verbose status update. She had just talked to her doctor, who requested antibiotics for Group B strep, and asked her to refrain from eating.

10:31am
Just got done talking to the doctor. I will be able to get pretty much everything I wanted except two things: I need an iv for group b strep but labor is almost over so that's ok. And no eating. They let me drink though

1:17pm
So sleepy

Four hours go by with no dilation progress. Is this cause for concern? No. The cervix has two jobs in the first stage of labor: to dilate, and to efface. This means it needs to thin out on the bottom. The muscle gets displaced to the top of the uterus, where it will be used in the second stage of labor for pushing. Before pushing can begin, the cervix needs to be 10cm dilated and 100% effaced.

2:41pm
100% effaced. 7 cm dilated. Baby at 0 station. Contractions make me feel like I'm going to die

Birth

Forty-five minutes later, after dilating 3cm and after just three big pushes, the next status update is one of jubilation (note the exclamation marks).

4:44pm
Baby is born!!! 3:28 pm!!!

7:58pm
Meant to post this earlier but he was 9 lbs 15.5 oz and 21.75" long. He's doing great. Both mom and baby's sugar was great (surprise surprise). He nursed well and fell asleep in my arms.

Facebook baby

Later, in the day after the birth, Amy explained: "I was not confirmed 10 cm when I pushed. I had been measured about 10 minutes earlier, and was still at 9[cm], but I didn't care." The contractions pushing contractions were too overwhelming. "Actually, after three hours at 7[cm] I pushed a little through contractions because it made it hurt less."

I pushed on hands and knees -- two pushes for the head then rolled over to my side for one body push. When I got on my hands and knees I could not help but push. They kept trying to tell me I'd know to push if I felt like pushing between contractions but that didn't happen. It was an incredible need to push during contractions that did it for me. Bill had a good analogy: He said that when I was squeezing his hand, he had to squeeze back as hard as he could so it wouldn't hurt. I told him that is exactly how I felt about pushing through contractions.

Amy added that the nurses begged her to get on the bed in the traditional supine (on the back) position, knees by her ears, to push. Loathing this position, she abstained: "I can't." Pushing, the head was born as she was on her hands and knees. It was only then she was able to roll onto her side.

Congratulations, Facebook Mom!

Conclusion

There are a few key points to take away here.

The first is that babies do not always come on their due dates. First babies are usually late; even subsequent babies can be very late. Amy's baby came over two weeks after her estimated due date. Due dates are just that: estimates.

Next, labor can start very slowly and progress over the course of weeks. This does not mean that life stops: Amy showed how to handle a slow-starting labor and the rest of her life. She did not let pre-labor alter her routine.

Then, the in-labor measurements of effacement and dilation are also estimates. The way these are measured is largely subjective. For dilation, the nurse or doctor inserts two fingers into the vagina, spreads them gently, and estimates the distance between them (this is why measurements are frequently preceded by "probably" or "around"). For effacement, the thumb and forefinger lightly pinch the cervix, and the doctor or nurse estimates how thin it is compared to other women's cervixes they have seen. This is more of an art than a science, and is sometimes not totally correct -- as in Amy's case, in which she began to feel like pushing before the necessary 10cm mark.

Finally, Amy showed that, by listening to her body and under the care of her medical professionals, she could have the strong, empowered birth that she longed for. Maybe it was not the ideal birth, both from the medical perspective (they wanted the baby out before the 2-week overdue mark, and they wanted her to push supine) and from her own (her doula did not make it, she had to struggle or argue for her body's rights, and she took some serious risks by skipping her prenatal appointments until so late in pregnancy), but it was within the realm of possibilities and, in the end, everyone was healthy, happy, satisfied.

Advancement to candidacy

2011-02-19T15:54:00.000-08:00

I advanced to candidacy (O glorious day)! It was a strange advancement with an unpredictable outcome. In this article I itemize the six surprises, much like the seven gates of hell (with one reserved for future implementation) through which I passed on the way to the positive outcome.

The Gates of Hell by Auguste Rodin
share little resemblance to advancement
to candidacy.

In my department, the advancement to candidacy signifies several simultaneous milestones that, in other departments or in other universities, are separate events. First, it implies that all courses for the program are complete satisfactorily. This includes core and required classes, electives, breadth requirements, and the requisite number of units within the department. Second, part of the advancement is the qualifying exam, which takes the form of an in-depth question-and-answer session with the advancement committee members (like an oral examination for which you do not have the questions in advance). Third, it is a defense of the research proposal and n-year plan. Approving the research defense is an indication that the student has enough background and domain knowledge to venture off on his or her own research topic.

Anatomy of an advancement

The advancement goes like this. First, the student (and student's friends, if any are available) arrive to set up some snacks. This is very important, because the whole procedure takes at least three hours, and everybody knows that hungry advisors are unhappy advisors, and unhappy advisors are likely to fail their students. Quality food is best, though sweets and carbs are usually a hit. At one advancement I attended, the student's wife made fresh, home-made chili and zucchini bread. Another had a giant bottle of organic orange juice. Yet another had an assortment of pastries and chocolates from an organic foods store nearby.

Ideally, the student arrived with enough time to set up his or her computer, connect it to the projector and Internet connection, and mentally and emotionally prepare him- or herself for the ordeal to come. It is not exactly a snake fight portion of your thesis defense (that part comes in a few years), but it can be a long and exhausting test of mental strength.

Colleagues, cohort, and friends arrive. The committee members, of which the student has at least four, arrive promptly, and the student begins his or her research goals presentation as other audience members filter in. Motivation, prior work, theoretical underpinnings or significance, proposed contribution, work plans, and a timeline. Then, the floor is opened to questions from the audience. When the student has sufficiently satisfied the easy audience questions, everyone leaves the committee alone with the student. The committee members ask their tougher questions (this is the oral examination). This can take over an hour. Having satisfied the committee, the student leaves, and the committee deliberates in private while the student paces outside in the hallway, waiting to be called in. Soon, the committee calls the student and discusses their decision (which is hopefully a positive one). The decision along with key points of the deliberation are written up and submitted as evidence of completion of this milestone. The student pays a fee and -- poof! -- is a Ph. D. candidate.

Anatomy of my advancement

I arrived with half an hour to spare for my 9:30am advancement with a collection of bagels and spread, nuts, chocolates, and other snacks from Whole Foods, and a gallon of Peets Coffee with organic cream and fancy brown sugar cubes (my husband was amazing and did all the shopping). While my husband and some friends were setting up the food, I went to pick up the projector I had reserved the night before.

"Just pick it up from me," the graduate advisor for my department, a sweet older lady in a darkened room lit by only a 25-watt table lamp, said when I made the reservation in person.

"My advancement is at 9:30am... will you be here?" I asked.

"Yes, I will," she said, and went to hang up the announcements with my name and abstract printed on them.

So, on the morning of my advancement, I was met with...

Surprise #1. The advising staff lady for my department decided to work from home that day. OK, no problem, I thought. I'll ask the other department's grad advisor, whose door is right here.

I knocked, but no answer.

I walked down the hall to faculty support.

"My advancement is in half an hour, and I have no projector," I said.

"You needed to have reserved one through your department's advisor," the girl behind the counter said.

"I did. She isn't here today," I replied.

We both leaned over and looked down the long hallway to the row of closed advisors' doors. She looked down at her reservation book.

"I don't have any projectors available," she said, with a sad note in her voice, "and no access to your grad advisor's room."

At this point, my friend Cat found me. "I have one in my lab," she said. "I'll bring it down."

I went back to the room of my advancement to set up Skype for the committee member with a sick baby to connect from home. Then, I was met with...

Surprise #2. An e-mail from another committee member that said he was sick and would not be coming. Just like that. It is probably no big deal, I thought. That's right. No big deal.

As the time drew near and passed, the room filled with people. Eventually the majority of my committee arrived, and I began my talk. Much of it was about a childbirth video game that I had invented, developed, and deployed, and where I planned to go next with the topic. When I finished, there was a lot of discussion among the audience, and I fielded questions. And then...

Surprise #3. My committee chair said, "I don't play games, and I don't have children, so I'm not probably the worst person to be on your committee." (At this point, I amazed myself with my own poker-face ability.) "How are games better than pamphlets you can get at the doctor's office?"

Hang on, what?

"It's just that I don't see how playing this game ---"

"Simulation," I corrected.

"How playing this simulation is going to prepare me for childbirth. I'd rather read a book."

Before I could reply that he, esteemed committee member, was clearly not my target audience...

Surprise #4. One of my colleagues in the audience replied, softly yet firmly: "If you were going to learn to fly a plane, would you specifically avoid flight simulators as training tools just because you don't believe in games?"

Then, a games-as-learning-tools debate ensued... one in which I was not involved. Very surreal.

The public Q&A ended, and nothing particularly out of the ordinary happened behind closed doors. My Skype-advisor asked some tough questions but was on my side throughout the whole process, even flashing me a big grin and double-thumbs-up on the screen when she thought nobody else was looking.

One committee member said, "Now we will talk alone and vote. You can leave the room."

"Should I just... uh, how will I know you are done?"

"Just wait outside the door and pace the hallway nervously," he replied. "It's tradition."

Rather than pacing, I looked down the hall and saw that the other department's grad advisor, a younger woman with a lot of blonde curly hair, had come in. I thought I would use this opportunity to ask about my missing advisor. When I told her what had happened, her eyes got as big as dinner plates and she picked up the phone, dialing a number with her long fingers, without taking her eyes off me. Then, she turned away and tersely described the situation to the person on the phone: "There's an advancement candidate here, and one of her committee did not show up. What does she do?"

Then: "I see."

Then again: "I see."

Surprise #5. Turns out, you actually do need all of your committee members. See, there need to be three tenured faculty that vote on whether or not the student passes. Failing that, the advancement is nullified and must be repeated. I had two tenured and two untenured present (including my Skype-advisor). My heart skipped a beat before sinking; my face paled and reddened and paled and reddened in rapid succession.

The grad advisor turned to me, placed both hands palm-down on her desk in front of her, and looked at me sternly.

"You tell your committee to get him" (the missing committee member) "on the phone. Drive to his house. Whatever. He needs to cast a vote."

"And," she added, "we never had this conversation."

As I paced outside the room as required by tradition (I was ready to do so now, as this was the killer that finally broke my confidence), I waited. I knew the gallon of coffee would come in handy: as the committee left, one at a time, to go to the bathroom, I notified them of this new development.

Over an hour passed. There was no way it was so hard to decide to pass me.

Finally I was called back in: "Congratulations, Candidate. We got his vote on the phone." But I was not prepared for...

Surprise #6. "We want you to switch departments." So that's what all the deliberation was about.

To be continued...

Why StarJeweled should be a co-op game

2011-02-18T23:32:00.000-08:00

In this blog post, I admit to cheating.

How I cheat in StarJeweled

In StarJeweled, a custom map for StarCraft 2 (Blizzard, 2010), you summon units and cast spells to destroy the enemy base. The units and spells cost energy, which you get from forming 3-in-a-row combinations on the right-hand side of the screen in a seemingly-unrelated mini-game similar to Bejeweled. When one move creates a cascade of combinations, you get tons of energy, up to 1000, which is the highest number of energy you can have at one time. The game awards points based on the total amount of energy collected and the number of enemy units destroyed.

Now, as a casual gamer that is not really into real-time strategy (RTS) games (and, frankly, is very bad at them) and vehemently opposed to violence in games, the right-hand side of the screen, the part with the jewels, is great. The rest of it, not so much. My husband, on the other hand, is an RTS ubernerd. So, we play together.

I use a small Wacom tablet as a pointing device and play the jewels portion of the screen. The Wacom is a necessity for ergonomics: when I use a mouse for this task, I hurt for days. So, my chair is pulled alongside the desk and the tablet rests in my lap.

My husband uses the keyboard and has memorized the key shortcuts to summon each unit. He watches the energy bar and performs the appropriate RTS-y action. When he needs a spell cast, he hits the appropriate hotkey, points with his finger at the screen, and barks an order: "Need a lightning, here." Or, "Freeze the big guy."

Needless to say, we outscore everybody. Despite my blunders such as locking our own unit, casting heal too late (and healing our free units), and generally not having the slightest idea about what is happening on the battlefield.

A lesson from a predecessor

Warcraft 3 had a fun little mini-game called Tower Defense. In this co-op game, three teams of players would face off in planting towers to guard the lanes down which enemy creep (units) would run. The towers are paid for in money, which you get from killing creep, which are summoned from the magic base at the bottom of the screen.

My friend Mike and I had a winning strategy here too. At the beginning of the game, we would share resources, which allowed us to pool our funds. He would build the minimum number and power of towers, and I would do all of the summoning. At the start of each new level, I would transfer money to his account and he would build more towers. I could monitor the upgrade level each opponent's base, and he could monitor his towers. (Bonus points because my computer was incapable of rendering the towers shooting more than about 5 creep at a time.)

We won every time.

But it affords two players

But StarJeweled game simply lends itself to two players so beautifully. Like pair programming, we share a single computer and think aloud to each other. It is truly a cooperative experience.

If StarJeweled supported a co-op mode in which, as in Tower Defense, we could share resources, it is likely that my husband and I would play on two different accounts, on two different computers. It is likely that we would not cheat by using two players for one game; instead, we would buy a second StarCraft 2 account, like normal people, and play the mini-game on an even playing field.

Just a heads up if you come across us in StarJeweled... we will kick your butt.

The nighttime smells like hospitals

2010-12-07T13:36:00.000-08:00

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.

Epidural birth and doula support

2010-12-05T15:35:00.000-08:00

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.

Meeting

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.

Birth

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.

Conclusion

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.

Two reasons Facebook is killing information retrieval and collaboration

2010-11-13T22:33:00.000-08:00

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:

Click on my name to go to my profile and wall.
Search the page in my web browser for the text I think I put in the link text.
Finding nothing, scroll to the bottom and choose "Older posts."
Wait.
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.

C-Section and doula support

2010-11-12T22:50:00.000-08:00

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.

Book report: The Woman in the Body

2010-11-09T19:59:00.000-08:00

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

My score
7/10

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.

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.
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.

Conclusion

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.

References

[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: http://www.jstor.org/stable/800352

Teaching Childbirth: Top 5 Tools of the Trade

2010-11-03T11:49:00.000-07:00

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.

Conclusion

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.

Note

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

References

[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.

Only women would find this interesting.

2010-11-01T13:59:00.000-07:00

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

2010-11-01T13:45:00.000-07:00

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.

Conclusion

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.

References

[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?

2010-11-01T13:40:00.000-07:00

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.

Sources:
BabyCenter: The Stages of Labor

Cow Clicker: Heuristic Evaluation

2010-09-15T22:26:00.000-07:00

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!

Moo!

Toddlers and Judaism: an apology

2010-09-09T14:36:00.000-07:00

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.