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.

Five hundred hours

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

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