Choosing a birth facility in five easy steps

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

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.

1. 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.
2. 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.
3. 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:

1. Oxygen getting to the uterus, and
2. 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. 

1. 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. 
2. 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.
3. 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.

1. 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?
2. No animal has birthing breathing rituals in the wild. Have you ever seen a dog giving birth to puppies while yoga breathing?
3. 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

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.

Why I'll never be a nurse

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

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

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

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

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

"Yikes," I said.  "That's heartless!"

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

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

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

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

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

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

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

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

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

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

I am a technical woman.

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

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


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

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

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?