Epidural birth and doula support

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

This could not be farther from the truth.

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

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.

My first birth: a doula's-eye birth story

This is the story of my first doula experience. It was an unmedicated birth. Early labor lasted days; active labor was about 3 hours; second stage was 2 hours.

My first client was a good friend whom I had known for several years as a technical woman. I will call her Sue, and her husband Joe.

(As an aside: I am really going overboard on accepting this term, "technical woman," which I heard at the Grace Hopper Celebration for Women in Computing. There was a montage shown at the beginning of the conference with women singly, in pairs, and in groups saying, in English and other languages, "I am a technical woman," all too enthusiastically. So now, all women in computer science and engineering are "technical women," and I have a mental image of them saying, with a grin, "I am a technical woman!")

Sue was waiting for a long time to go into labor. When she had contractions every day for the last five weeks of her pregnancy, each day seemed like it would be the last: today is the day! Any day now! But alas; the little boy inside of her hung on tightly to life in utero.

After a failed induction (who knew Cervadil could just fall out?), Sue went home, sad and dejected. But she was hardly home a few hours before the light, Braxton-Hicks contractions intensified. Timing them, Sue and Joe saw they were about three minutes apart -- and they went back to the birth center.

I got the call at 10:45pm and was on my way to the birth center at 11:15pm. I was nervous, and a little embarrassed knowing I had performance anxiety. This was my first birth! How can I help my woman-friend handle her labor when I could not even handle my own labor? I remembered how scary it was to be on uncharted territory, when the pains of labor ebb and flow. I was scared she would call me on it when I tried to comfort her: "How would you know?"

When I arrived, everyone was exhausted. Joe, having been up the previous night from a combination of the uncomfortable guest bed in the birth center room and nurses coming every few hours to check on Sue, was struggling to keep his eyes open in the bright lights of the triage room. Sue stood and hummed through short, frequent contractions.

The nurse came and checked Sue, and admitted her. The room was one of the few with a large jacuzzi tub, with jets and fancy fixtures and detachable shower head, and large, warm tiles on the walls. Quietly, we rejoiced between contractions, and marveled at our excellent luck.

"I'd better really be in labor this time," Sue said. "We've hit tub jackpot." Sue climbed onto the bed and raised her rump in the air during a contraction.

The nurse came and offered Sue a sleeping pill to rest.

"If you're not really in labor, the pill will help you sleep. You'll need the rest in the morning. There's a chance that in the morning, when you wake up, you'll suddenly -- wham! -- be in active labor," the nurse said encouragingly.

"And what if she is already in labor -- what will the pill do?" I asked.

"Then she may be able to rest between contractions."

So Sue took the pill, and I dimmed the lights and pulled out the inflatable futon. Joe lay on the guest bed and was asleep within seconds. I helped Sue get settled on the rocking chair, where she was hooked up to an external fetal monitor. I lay down on the futon, and within a few minutes could hear the even snoring of my client and friend. Every few minutes the snoring would stop and the chair would rock back and forth. Then, the chair would stop, and the snoring would resume. It was graceful.

At 6:00am the nurse returned.

"Your labor isn't progressing," she said. "You are still a centimeter-and-a-half dilated, and the contractions aren't strong enough to open your cervix."

I went home to nap and to feed my son.

At 10:45am, exactly twelve hours after the first call, Joe called again.

"We've decided to have our waters broken," he said.

"Great," I replied, and reminded him of the pros and cons while pulling on my jeans.

When I arrived at 11:15am, the sunlight was streaming in the birth center's floor-to-ceiling windows onto the polished hardwood floor. Sue stood in the middle of the room, moaning, her thick, black bangs covering her eyes. Joe stood beside her and rubbed her back. Sue's membranes had not been broken for fifteen minutes, but her contractions were really working.

I put down my gear on a counter and observed a few contractions. Noticing she liked to stand, I suggested some standing positions, such as leaning over the birth ball on the bed, or leaning on Joe. I asked if her back hurt. Sue shook her head. No back labor: great.

Suddenly, Sue tore off her hospital gown and stood leaning against the wall, her elbows over her head, and moaned. Joe rubbed her back in brisk circles. This is it, I thought. Active labor, when the clothes come off.

The nurse came and started a heplock (the IV without anything going in) and monitored the baby. She left the room with the monitors still attached because she needed twenty minutes of continuous monitoring. A few minutes after the nurse left, Sue stood up off the bed, exclaiming that the bed is a terrible place to labor. Joe and I watched the contractions on the tape spike and multiply. One of two things happened: either the monitor's output was unreliable in the standing and leaning-forward positions (very likely), or the contractions intensified immensely (equally likely).

When the nurse returned, she sighed at the ruined tape but did not make Sue repeat the procedure. She asked Sue how she felt.

"The tub," Sue roared. But Sue's nurse, the one that remains in contact with Sue's obstetrician, was out, and this one could not give Sue the go-ahead to get in the tub. The nurse went back to her station. Joe and I tried to soothe Sue in other ways, but with each contraction Sue told herself and us that she counts the minutes until she can get in the tub.

I went to the nurse's station to see what was the holdup.

"Sue's nurse is at lunch," said the nurse that came to check on us. "She will be back very soon. Just hang in there. Go ahead and fill the tub with warm water so it's all ready when she gets back." Great advice! I went back into our room and did just that.

In a few minutes, Sue's nurse indeed returned, and by 1:00pm Sue was lounging in the tub, moaning with each contraction, her belly turned to the right and her head to the left. As the minutes slipped by, the door into the bathroom closed more and more, leaving us in a dark, echoey room. Every hour or so the nurse would come to see how we were doing. Once, she brought an LED candle that flickered peacefully, but Sue's eyes were closed tightly. Joe held her hand above the water to keep the heplock dry, and stroked her forearm during contractions. Sue moaned.

"Guys, I'm not kidding," she suddenly said between contractions. "I want drugs."

Joe turned on the tub and looked at me, eyebrows raised. I tightened my lips and shook my head slightly. "You're doing so well. You're rocking this," I said. Joe nodded, turning back to face Sue.

"You're doing great," he said gently to the dark, round form in the water below his face.

"I don't want to be doing great. I want to not be in pain."

I knew this would come up. Sue and I talked about pain management in detail in the weeks before the birth. She knew the pros and cons of pain medication, and, more importantly, knew how violently her own body reacts to medication. We decided to work together to have a drug-free birth. She told me, in our conversations, to question her and deny her drugs; to remind her of her birth plan; to tell her how well she is doing; to do whatever it takes to keep her from choosing an epidural or anything else.

But now, she was pleading with us. She said please. She said it over and over. She told us she was suffering (we had both read in a book that laboring women that were doing well may be in pain, but they were not suffering -- so this was particularly touching to me).

I persisted: "You're doing great. You're in transition. This is the part that sucks." And all the time I was wondering: am I doing the right thing? And I was scared: what if she says, "How would you know?"

One notable thing about her drug requests is she never asked for drugs from the nurse. This is one way I knew she did not mean it. The other way I knew is that Joe never once turned around again. He kept all of his focus on Sue, and we all moaned with her.

An epidural is a fantastic medicine that can be used at a point of exhaustion in the mom, to let her sleep. This is arguably the epidural's best use. Other good uses are later in active labor, but not too late, so that the drugs wear off before pushing, so that mom can feel the baby, and so that baby would be awake for the active part of his or her own birth.

Sue was in transition, and it had only been three hours since the breaking of her waters. She was doing great.

When the nurse came in again at 1:45, she offered to check Sue's progress. With the door ajar and more light in the room, Joe and I could see fresh blood in the water near Sue's bottom. I turned to Joe and said, "See the blood? That means the end is near." Climbing over the tub and balancing on the far edge, in a perfect model of alacrity, the nurse meanwhile checked and exclaimed: 7cm! Just then a flurry of contractions hit, and Sue was again carried off by the tidal wave of labor.

Joe and I tried to keep up with Sue's contractions. I felt distant from her; she was lying motionless in the water between contractions; the water was chilly. When I said something, I did not know if she heard me. But she was so relaxed both between and during contractions, just like I had seen in dozens of birth videos, that I thought she was doing well. Mostly, Joe and I moaned with her. A couple of times, we did not. I had no idea if it was annoying or helpful to have us make noise. Later, Sue confessed she felt lonely when she was the only one vocalizing; she appreciated us all moaning together.

The next time the nurse came in, it was 2:30, and Sue's bath water was icy cold. Sue's moans had turned into yells. She paused at the peak of the contractions, her breath held. A sharp smell trickled into the air from the bath. The nurse again balanced on the edge of the tub and checked.

"You're complete."

She gave Sue the option of staying in the water to try to push, or getting out. Sue decided to get out. Later, she told me she promised herself that she would only get out of the water for two reasons: drugs, or pushing.

On the birthing stool, which is like a chair with no bottom, she gave her first mighty pushes. During one, her bangs temporarily parted and she looked me in the eyes as she roared. She was the strongest woman I had ever seen, and I was a little taken aback. She roared, throwing her head back, powerfully, as blood oozed onto the floor.

The nurse's shift was over. She left, and two young nurses came to take her place. They looked terrified of the raw power we had in our room. They attached monitors to Sue's belly and looked at her progress. Then, they gave her some advise to help the pushing go faster: tuck your head in; make a C with your spine; hold your breath. It is the last few moments of pushing that really moves the baby. They started to count to ten. Three count-to-ten pushes per contraction. Let's do this. They moved Joe behind Sue so she could lean back on him between contractions to rest. I sat by her knee and held a cup with ice chips and a spoon.

The baby was really coming now. Sue gripped the squat stool and pulled it up toward her head, making a perfect C with her spine, and holding her breath as Joe counted softly behind her head. I could see the head quartering. I said, "Reach down and feel your baby." Sue reached her hand down and startled, pulling it away and yelping. I laughed, my eyes filling with tears a little.

The nurses suddenly realized that the baby was not far.

"Oh!" said the older nurse. "We need to get you on the bed. I could catch the baby, but I don't feel comfortable doing it in this position, and we need to wait for the doctor." The younger nurse ran out of the room to fetch the doctor. "We need to slow down the descent to, uh, to protect your perineum. Let's get you on the bed." She looked frightened.

So Sue got up from her squatting position and put one knee on the bed. Several contractions nailed her into this position. She tried not to push. Eventually she made it on the bed, and immediately the doctor walked into the room. She did not rush, she did not waltz, but really unremarkably just walked into the room. The nurses dropped the bottom of the bed.

"What are you guys doing in here?" she asked. Baffled, we looked at her. "Having a baby? Great!" she said, and put on a gown and gloves.

Barely having a chance to sit down, the older nurse grabbed Sue's right leg, I grabbed her left leg (Joe was at her head as usual, holding her hand), and with one more mighty push, the baby was born. It was just after 4:20pm. The nurse placed the baby on Sue's belly.

"Baby!" said Sue in her normal voice.

And, as I expected, my eyes filled with tears again. But I was busy: I grabbed the camera and started recording. For a long time, the baby lay on Sue's breast, still attached. Then, Joe unceremoniously yet very paternally cut the cord, and the baby was free: a life of his own.

So, where was I useful, as a doula? I honestly did not feel I did anything remarkable. There were no heroic measures, no advice I provided nor did Sue do anything I suggested. I asked Sue later how I could have been helpful when Joe was there with her, doing everything right: holding her hand, speaking to her in that tone of voice she loves, rubbing her back, and being strong. She said with me there, he felt empowered to do these things. He followed my lead. Since I remained calm, he knew everything was going well; he provided support when I provided support; he moaned when I moaned. Hearing that, I felt strong, and useful.

And boy, was I glad Sue never said, "How would you know?"

I cannot wait to support another mom in childbirth.

Any day now

Any day now: This was my standard post-37-weeks answer when anyone would ask, gazing at my large, round form, when my baby was due. Even knowing that most first-time mothers do not deliver before 40 weeks (I think 41 is the mean), somehow I knew that, at 38 weeks, it was "any day now." I delivered at 38 1/2 weeks.

My first doula client is due any day now. That is, she is about 35 1/2 weeks along but it is becoming clear that it will be soon. Her baby has dropped ("lightening") and is in position. She has been having fairly consistent Braxton-Hicks contractions for six days, getting progressively stronger. And at home, she has been boiling diapers and hanging clothes lines. Sure, it could take another month, but probably not. If she holds out until Sunday, she can deliver at the birth center rather than the hospital. Hang in there, girl!

As the time draws near, I am both excited for her and apprehensive about my own role as her doula. She is my first client, and I have quite a bit of performance anxiety. What if I do not fulfill her expectations? What if I say or do something wrong? And my biggest fear -- what if she feels unsupported, afraid, and alone?

There is only one way, short of those hypnosis re-trainers of dubious credentials, to get over something, and that is to do it. My mind tells me I will be a fine doula for her. I know her well, and we have discussed all aspects of her pregnancy at length. She is as overprepared as I am. Yet as my mind is certain I am ready (and prepared) to be a strong and gentle support person in her labor, my emotions are raging. I have even been having anxiety dreams!

Do doulas get labor support -- while on the job? Maybe I should hire one for myself!

Book report: The Breastfeeding Answer Book

Mohrbacher and La Leche League International, The Breastfeeding Answer Book, Third Revised Edition, 2003

My score

10/10

Amazon link

The Breastfeeding Answer Book

My review

This is a hard-core reference book. This is the book our local lactation consultants use. It is the single most complete, amazing breastfeeding resource I have found. Of particular note are the first few chapters, which discuss changes in our knowledge of breast anatomy, and what we know now. Understanding how the breast works puts so many other breastfeeding problems into perspective. Written with the lactation consultant or other support person in mind, the book first addresses active listening and how to ask questions without prying

This reference really does answer most breastfeeding questions, from nursing in the early days to teething, from nursing strikes to weaning, to the practical issues of nursing a toddler. Answers are comprehensive and supported by cited, peer-reviewed papers. Each paragraph in the book has a one-sentence summary in the margin.

Anyone taking breastfeeding seriously, as an art as well as a science, should get this book. You wouldn't take a circuit design class without buying a circuits textbook... similarly, you wouldn't consult a woman on breastfeeding without this book.

Book report: Ina May's Guide to Childbirth

Gaskin, Ina May, Ina May's Guide to Childbirth, 2003

My score

8/10

Amazon link

Ina May's Guide to Childbirth

My report

The book starts with some awesome birth stories - very inspiring and inspirational. The births are mostly set on The Farm, a birthing community deep in Tennessee, supporting natural midwife-driven childbirth. The following chapters aim to persuade the reader that "the body is not a lemon;" that in the vast majority of cases, natural childbirth is possible, and, moreover, preferable to childbirth with interventions. Ina May cites both The Farm and other natural birthing communities as well as European nations that have a high home-birth rate, low intervention rate, and maternal mortality rates drastically lower than that of the USA. In particular, she calls for greater accountability among medical professionals for maternal mortality rates - in the UK, for example, there is a complicated process of investigation into maternal deaths which results in a book called Why Women Die, which anyone can buy from the book store.

Ina May argues that labor need not be painful: that with relaxation techniques the "rushes" are felt more like intense pressure rather than pain. The Sphincter Law is that it's impossible to relax a sphincter under pressure.

Book report: The Thinking Women's Guide to a Better Birth

Goer, Henci, The Thinking Woman's Guide to a Better Birth, 1999.

My score

6/10

Amazon link

The Thinking Woman's Guide to a Better Birth

My report

Heavily biased towards natural childbirth, this book presents bulleted lists of pros and cons for interventions during labor and birth, and presents alternatives for undesirable interventions. If it weren't for the strong agenda, this book would be great. The book uses shock value by starting right off on the discussion of C-sections, then continues by discussing the interventions one by one in decreasing invasiveness. One of the main points in the book is that obstetrics is mismanaged, backed by overwhelming statistical evidence. I like the simple language and easy reading of the bulleted lists. If presented with an intervention, one can flip to the proper section and quickly research its pros, cons, and alternatives.

Book report: The Doula Book

Klaus, Kennell & Klaus, The Doula Book, 2nd edition, 2002

My score

5/10

Amazon link

The Doula Book

My review

This little paperback provides an overview of the duties, benefits, and experiences of a doula. The first four chapters take the reader on a touchy-feely journey on the good things about having a doula before and during labor. The following four chapters provide summaries of randomized trials regarding doula care. Every trial concludes that having an emotional support person (doula) present continuously throughout labor and delivery significantly reduces the chance of intervention, from epidural to C-section. The most shocking study is from Guatemala, in which the labor and delivery experience was half a dozen women in a single room, attended by one nurse that comes and goes, with no pain relief. It sounded like my mom's birth experience. In Guatemala, half of the women were assigned a doula that stayed with the women throughout labor; their success rates as far as minimal intervention were phenomenally higher. The Dublin Experience is a case study of a maternity hospital in Dublin, Ireland that assigns each mother a nurse midwife during labor; the intervention rates at this hospital are incredibly low and the maternal experience is rated incredibly highly. Moreover, the length of labor is decreased compared to the labor length at the same hospital prior to the introduction of the constant emotional support person. Finally, postpartum care is addressed from the point of view of a postpartum doula, who helps with breastfeeding, care of the newborn and the parents (who, it is pointed out, also need to be mothered during this delicate time), and household chores.

The appendices are arguably the most useful sections of the book as a reference (although the summaries of the trials were interesting as well). Appendix A discusses the training of a doula and how a doula prepares for her work. Additionally, the appendix discusses what happens to the laboring woman during the stages of labor, how a doula can help, and ways she can tell that it's time to seek medical attention. Methods of interacting with a woman that has undergone abuse are discussed. Appendix B lists in detail several self-hypnosis and relaxation meditations.

Many of the findings are summarized here, in Touch and Labor in Infancy.