Monday, November 12, 2012

You Learn Something New Every Birth

doulas

I'll admit, I don't usually back my doula bag until my client's are 40 weeks. I know this isn't perfect doula practice, but there are two reasons: 1. My bag stays almost entirely packed with my doula tools all the time anyway (I just have to add things like toiletries, snacks, medications, phone charger, sweater, etc), and 2. My clients never seem to go into labor before 40 weeks.

This is another reason that I find the whole "40 weeks is your due date and then after that you're late" thought-process to be completely flawed. Nearly all my clients have gone into labor AFTER their 40 week mark. There is no timer to go "ding!" that means you are "done" at 40 weeks! (but for more on estimated due dates, see this other post, or this one)  And not just first time moms!

Back when I was a brand new doula, my bag used to be packed at exactly at the 38 week mark. I was also more paranoid in general - not a single drink during my on-call period, no foods with onion or garlic (so my breath wouldn't smell bad), obsession with checking my phone all the time and with every single plan I made (can I go to the movies?), and so forth. I remember each birth that occurred prior to the due date:

I had a first time mom go into labor before 40 weeks, but that was an effort on her part - she asked her midwife to sweep her membranes at around 39 weeks (see bottom of post for an explanation if you don't know what this is), and it worked the very same day. I knew in advance why she wanted to go into labor earlier than her due date and she kept me informed of her techniques.
A third time mom went into labor at 38 weeks, a week after I met her and she hired me.
I also had a first time mom go into labor on her exact due date, which is so rare that it was shocking.

And then just recently, with no warning at all, I got a phone call in the middle of the night from a mom who had no major warning sign that she would give birth before 40 weeks (other than the fact that she really didn't want to be pregnant anymore, which is like most women), and had to scramble around and pack my bag! I found out that she was taking evening primrose oil capsules, on her midwife's advice. I'm not sure why she was taking them, or why the midwife advised her to take them, prior to her estimated due date. Perhaps the midwife always prescribes it. Perhaps the mom was incredibly impatient and so that's why the midwife suggested it.

Evening Primrose Oil is a supplement that can ripen the cervix because it is high in prostaglandins. Prostaglandins are sometimes administered directly in the vagina by a doctor to prepare for a labor induction. Semen also contains prostaglandins, which is one reason why they say sex can start labor! Evening primrose oil doesn't exactly induce labor; it helps soften the cervix in preparation for labor. I don't know much about EPO so I asked about it on twitter.  Respondents said that it can have side effects and should not be used routinely and perhaps not unless an induction is looming for post dates, and that there is not a lot of research on EPO. Apparently side effects can include upset stomach and headaches.

A quick survey of the literature came up with a retrospective quasi experimental study of 108 low-risk nulliparous women that found:
Findings suggest that the oral administration of evening primrose oil from the 37th gestational week until birth does not shorten gestation or decrease the overall length of labor. Further, the use of orally administered evening primrose oil may be associated with an increase in the incidence of prolonged rupture of membranes, oxytocin augmentation, arrest of descent, and vacuum extraction.
Another article on midwives' use of herbal preparation for stimulation of labor found that there were no reported complications in the use of evening primrose oil or red raspberry leaf tea and that evening primrose oil was the most efficacious herbal preparation for cervical ripening. Most else of what I could find just says that there is a lack of evidence. Basically, that more research is needed.

Anyway! She went into labor prior to 40 weeks and the labor and the birth went well. I always tell my clients that I will come when they feel they need me. Sometimes in the middle of the night I really hope that even though they're calling me, they'll see that their contractions are still "early labor" contractions and they won't "need me" right now. With this one, I did end up getting to her house a bit before an active labor pattern was established. This has happening to me a couple times. This is hard for a couple reasons: First, now everyone feels like we're in active labor mode and it's hard to not feel rushed once the doula is there and you feel like everyone is waiting on you and watching you labor. Second, it would be nice if everyone (mom, partner, and doula) all got some more sleep, but now sleeping arrangements are awkward. And third, several other things are also awkward - instead of needing active help all the time, we're hanging around at home watching TV and making lunch, etc. But the second ones are more about me, and so... see number one!

But it is also highly beneficial for me to come early in several instances. Once, it was because mom and dad had me meet them at the hospital and mom was only about 4 cm dilated. They walked around trying to decide what to do: Be admitted and be in the hospital the entire labor, being pressed for time and to adhere to the ridiculous "1 cm per hour" rule? Or go home and try to sleep, and hope that in their own environment labor would move along at a comfortable, un-stressed pace. Perhaps if I hadn't been there at the hospital to discuss things they wouldn't have gone home (and ended up having a great labor!)

Most recently, I was glad to sacrifice my time/comfort/sleep/whatever to be with mom and dad early in order to reassure them and keep them at home. This is a big one. I have been told so many times, "if it weren't for you, we would have just gone to the hospital at [2 am, 4 am, etc]!" And mind you, this is JUST after labor contractions start. You really shouldn't go to the hospital at the start of labor, for a multitude of reasons. 1. they might send you home if you're not 4 cm or more anyway, 2. hospitals can be stressful places where labor actually slows, 3. if you want a natural labor, the longer you are in the hospital the more likely things will be done that make this harder (i.e. stay in bed the whole time, pressure to get pain meds, you aren't allowed to [eat, drink, pee, use the shower for pain relief, etc], let's manage this labor a bit more with drugs, etc), 4. you will be rushed for time (it's been ___ hours since ___ so we need to do ___) even though there is no medical reason to do so, and 5. I could probably think of more if I wanted but I'll stop there.

Several times if I hadn't showed up right away mom and dad would have just listened to some direction (that always changes) like, "come in when contractions are 5, 1, 1" or "come in when your water breaks" or "come in so we can see how far you've progressed" which have no basis other than they just want to manage labor. I have been told a million times, "I am so glad we labored at home," and "this is really great laboring at home," and "I'm glad we didn't go to the hospital right away." And even from hospital midwives, who are impressed that the mom comes in at 8 cm or 10 cm because that is so rare for them (and I've even got a "way to go, doula!"). But it is hard, especially for first time parents, to want someone there with them to can reassure them about what is normal and answer a million questions about labor positions, eating and drinking, whether or not they should try sleeping or walking, and of course the big one - when should we go to the hospital? [And in this instance, interestingly, many a question was answered along the vein of "is this going to make the contractions worse? Such as "Is a cold beverage going to make the contractions worse?" and "Is a shower going to make the contractions stronger?"] I have witnessed many many more labors than they have and I know what a contraction pattern or mom's temperament means.

Just as an aside, I always let the couple decide when it is time to go to the hospital. I give advice if asked, but if they feel it is time, we go. The only instances in which I say "ok it's time to go now" are when mom says her first "I feel the urge to push"! And I should also add, here, that we've left while mom felt like pushing many times and always made it to the hospital in time (even with a third time mom); They have all still had to actively push for a period of time in the hospital. This is always a big worry, but the stories you hear about babies being delivered in the car are rare (though I'm not denying that is possible to wait too long to go, or to have an exceedingly fast labor).

Talking about doula self-sacrifice - my body was really aching after my last doula labor! Whoever thought that becoming a doula was all fun and babies, you should really recognize how hard being a doula can be, sometimes.

I also wanted to mention that a recent labor was attended at a Baby Friendly Hospital. I want to share this experience, because it wasn't quite what I thought it would be. Firstly, the nurses asked the mom immediately after delivery if she would be bottle feeding or breastfeeding. This is interesting in two ways:  1. I did actually think it odd that a hospital with the highest support for breastfeeding there currently is is even asking a mom if she is breastfeeding, instead of assuming that she would do the norm (and yes, wanting to breastfeed is the 'norm' - 75% of women in the U.S. initiate) and only require formula in case of complications (which is what formula should be used for), but...  2. For the people who say that going baby friendly hurts moms who want to bottle feed because it pushes breastfeeding on everyone, clearly if they are asking moms, this isn't true.

Secondly, I was under the impression that BFH's do uninterrupted skin-to-skin and make sure mom has help in trying to initiate breastfeeding in the first hour after birth. I was under that impression... (Perhaps you see where I am going with this?) This mom had her baby on her maybe 20 minutes of the entire first hour and twenty minutes of baby's life. They were doing the usual - weighing, measuring, drawing blood, eye ointment, letting dad take photos, etc in the baby warmer instead of letting all that wait and giving mom the chance to warm and feed and bond with the baby, all of which is good for both the baby's blood glucose levels and the breastfeeding relationship. Oh, and they did the typical swaddle the baby and we had to un-swaddle him to put him back on mom, and then they took him off a second time. And the entire time no one was helping with breastfeeding but me! Until finally a baby nurse came back in and then repeated EVERYTHING I had just been saying and doing. Grr. So frustrating. I do think this nurse was trained in lactation, luckily, but I don't know if all the nurses are, because all she said is "you can ask any nurse for help with breastfeeding." Which is what they all say everywhere, even if the nurses aren't trained in lactation.

The point of all this is... you learn something new every birth. Or many somethings. For instance, I also learned that if a mom is GBS+ she should really get the IV antibiotics in her system at least 4 hours before delivery (so don't wait too long to go to the hospital with a GBS+ mom).

Or sometimes, many things are affirmed. For instance, you really can't tell if a mom is going to take one hour or several hours to go from ___ cm to 10 cm. Or like how sometimes L&D nurses are all the same. And sometimes they're idiots (Sorry, just really annoyed at an L&D nurse who told my client to tell her if she had a continual urge to push,  even in between contractions, which is NOT how it works. And then wouldn't let mom stand beside the bed when she felt pushy because she was afraid she'd have the baby on the floor, even though she had just checked her and she was only 8 cm and was not going to push a baby out that fast. Ok, rant over).

Ok, POST OVER! Thanks for sticking with it til the end :)


--> A membrane sweep, or stripping the membranes, is not the same as breaking the bag of waters (amniotic sac). It is done by inserting a finger between the membrane that goes around the amniotic sac and the wall of the uterus to loosen the membranes from the wall. Sometimes this stimulation of the uterine wall can help to start labor. It doesn't work for everyone, may or may not be uncomfortable, and can sometimes cause the water to break.

2 comments:

  1. Ugh, unfortunately, working at a hospital I have discovered that Baby-friendly is only as strong as its weakest link. Different hospitals do it slightly differently, but in terms of documentation (part of what the BFHI team will look at) the nurse may just have to chart a "reason" the baby wasn't skin-to-skin, and can pick whatever she wants, or can count that 20 minutes as skin-to-skin, etc. You can have a great nurse who is skin-to-skin friendly or a nurse who has shifted her practice just enough to get by, but still does not truly practice skin-to-skin. Unfortunate that our clients still need to advocate for themselves in these settings, but sometimes they do!

    ReplyDelete
  2. That's a great way to put it! "Only as strong as its weakest link"

    Very interesting insight, thank you, Rebecca.

    ReplyDelete

Related Posts Plugin for WordPress, Blogger...