Birthing a Marathon?

mile 22

The way I see it, running a marathon and birthing a baby are very similar. I have attended well over 500 births (but under 1000 for those who are into numbers), and these three answers are the most common ones to the prenatal question I ask: "What is your greatest fear?"

• Dying
• Pooping in public
• Not being able to do it

I am a ravenous running nerd, and I read everything and anything to do with running, and I believe these are the three main fears of the marathon runner too: no one wants to die (hence the plethora of articles about people dying at races; no one wants to have to poop suddenly while running (more articles; EVERYONE worries about not finishing a race, for whatever reason.

When I am accompanying a pregnant woman, I may speak with her about her fears for the coming event. The number one fear is that her or the baby will die. Number two, fittingly, is that she will poop during the pushing phase. And number three, as in a marathon, is that she will have a DNF which actually is impossible in birth but, unfortunately, a definite possibility in every runner's mind.

Birthing and Running are the Same?

No, they're not the same, obviously, you can't compare a baby to a piece of bling!

You can compare some of the feelings, though. The hours, days, weeks and months of preparation. Finding a program or a method that matches your philosophy, or hiring a running coach (or a doula - we used to be called "birth coaches"); learning about nutrition; getting excited, then nervous, then depressed, then excited again; talking to other people who have done it ... of course, if this is your first baby or your first big race, all these feelings and choices will be felt and made in technicolor. If you're more experienced, you will still feel the same range of emotions, and you'll be "in the club".

That's where the similarities end, unfortunately.

Running the Drugs?

Runners, imagine this: You're at mile ten, almost half way through your marathon. You're keeping a good pace, maybe you started a little too fast, because this is your first. Your training went well, and you're feeling good. Mile eleven, you have to pee. You take a quick pee stop. At the next station you have a sip of Gatorade and you start to feel a little queasy, the way you ALWAYS DO when you have some carbs around miles ten to fifteen. You know this about yourself. It's a thing.

Suddenly, a car drives up and a bunch of people jump out, looking at their watches. "Your pace has slowed down too much! You're not gonna make your BQ! You might die!". In your head you know they're wrong, and you try to shut them out and run faster, anyway. But their worried expressions start to seep through your endorphin rush. "Oh, shit, does my heart feel weird?"

You let them know you're feeling a little tired, and you had that queasy feeling. All of a sudden, the car speeds up and they make you an offer: "Take some drugs, get in the back of the car, we'll drive you to the finish line, you'll get the bling anyway, all good, no shame, no worries." You protest - you're okay! But a voice in the back of your head says that actually, you're not okay. You need the drugs and you need the car ride. By this time, you're at mile 20 and you hit the wall. Take the drugs, get in the car.

Real Emergencies

Of course real emergencies exist, both during marathons and during birth. In those cases, there's no question that you need the damn car, preferably an ambulance, and you need drugs, and speedy medical intervention, and everything you could possibly grab for a life-saving conclusion to the RARE instance when you are actually in danger of losing your life (or if you're birthing, your baby's life).

Your Choice?

I'm not one of those airy-fairy militants who advocates a natural, candlelit birth for every woman. I've seen babies die, and I've seen women close to dying (Thank God for modern medicine!!). But I  do advocate CHOICE. I was just speaking to a fellow runner this morning. She's been running for twenty years and she's never gone further than 15k. She never races. She runs slow. Me, I've been running seriously for just over five years and I love to race. I push myself ... not too much ... but just enough.

I was at a race about a month ago - it was kind of tough: it was pretty cold and at one point the course turned into a muddy, icy puddle for about a kilometer, and it was a loop, so we had to do the puddle twice, once about the middle of the 21 k and once closer to the end. As I was coming up to the first mud puddle, I saw a runner with a weird gait... I got closer and I saw one of the yellow-jacketed medical people going over to him with a concerned air. The runner told him to go away. As I got closer, I heard him groaning with every step. He sounded like a woman in the deepest labor, feeling that baby's head right down low. A second medical person ran up to him: "Non, non, ça va, merci." ("No, no, it's okay, thank you!") I ran past him and didn't look back.

Here's the thing: I knew that if he was in that much pain already, there were two possibilities: either he would not finish the race, and spend months if not years fixing the damage he had wrought on his body; or he would finish the race and ditto. But, for whatever reason, he MADE THAT CHOICE and it was his to make. Obviously, if he was in cardiac arrest, or lying on the ground unable to move, the paramedics would be in there in a microsecond, doing what they need to do. But he was birthing a marathon HIS WAY.

Birth

I've witnessed a tiny number of births that ended up to be medical emergencies, where mother or baby could have died. But most of them are normal, scary, joyful, life-changing, painful, pleasurable, primal events. Unfortunately, the people who work in the maternity care field are usually unwilling to adopt the "marathon runner" model, and instead use the "air crash" model. In the latter, birth is simply an accident waiting to happen. In the "marathon runner" model, the birthing woman could be treated like a marathon runner: during the nine months before the event make sure you are healthy (I got a cardiac ultrasound done last year before starting my marathon training because of a risk of familial cardiomyopathy); create your team; and start preparing.

Let's skip ahead to the "event": the runner has been trainings for months. She followed a training program, or had a coach guide her through the realities of training to run 26 miles. The birthing woman has been preparing for this day for months as well, and she has been working with her team to make the upcoming event as pleasurable as possible.  Both the runner and the birthing woman have possibly been reading everything they can about their upcoming event, and both may have suffered setbacks along the way.

Running

And, now, what happens when you're running a marathon? You join a big, happy crowd of people, and you start. As you run the miles, you are handed water, energy drinks, yummy gels, bananas. All along the route there are smiling people, holding funny signs, cheering you on, giving you high fives ... letting you know you're doing great!

No one looks at you with a worried look, even if you're the oldest person in the race and the slowest (happened to me on my 60th birthday), they just keep on smiling and cheering, unless, like I said, you're on the ground.

Then why, oh why, did my lovely, young, strong, healthy, well-fed, happy labouring clients get the hairy eyeball from the staff when all they were doing was, basically, the marathon of the day. No smiles, no happy people handing you cute cups of water, no cute cups of energy drinks, no gels, no bananas, no funny signs, no high fives.

The epidural rate for first time mothers in Montreal hospitals is over 90% (don't look at the published statistics, they include second-timers who know better, and pull that statistic down to around 60%). Why? Because we focus on the fear aspect (YOU COULD DIE!!), instead of the fun aspect (YOU GO GIRL!!).

Fun Stuff

Yes, the truth is that running a marathon is just plain more fun, and more pleasurable, and better appreciated, than bringing another human into the world. Weird.

So, I guess that's why I don't attend births in the hospital too much anymore. It just kind of tickles me when I imagine birthing mamas being treated like runners - and how different it is from the reality:

"hey, I know you're planning on running the Barkely, but it looks really dangerous. I think you should run it attached to an IV pole."

Or, "hey, I know you're 60 and you're planning on competing in the World Marathon Challenge. This is super dangerous, why don't you just get really stoned and we will drive you around - you deserve it!"

Or, "you know you could die doing that? Running a marathon/birth/solo travel/sailing/(fill in the blank) is just too dangerous."

Yes, I know I'm gonna die one day, and I'll let you in on a secret - so are you. And so is everybody. But I really wanna have fun while I'm doing this crazy little thing called life. Spread the Love!

Thoughts on Solitude

We are all alone. We are born alone, and we die alone. This little albino lizard blends in so well with her surroundings, we can hardly even see her against the whiteness of the sand. But she is alone, just like you and me.

The most wonderful and valuable service a doula can offer another woman during her childbearing year is companionship.

The newborn is the most beautiful, alluring little creature. But he needs attention, breastmilk, love, concern...he is alone too, but he knows what he wants. He wants to be held, nuzzled, nursed, touched, loved.

Please be mindful when you are accompanying a woman on the journey of giving birth to a new life. Be mindful if you are accompanying her on a more difficult journey, when she is not having a perfect experience. Please be mindful when you are feeling alone, and remember that the air you breathe in has just been breathed out by another person. Please be mindful when you speak to a woman in labor. Be mindful when you stand next to an old woman on the bus. Be aware that your presence can mean a universe to a woman who is feeling alone.

Ask the Doula - epidurals

I am always getting letters, phone calls, or face-to-face questions about birth, doulas, and such.

Every week, I am going to  try to answer and explore a different question that is presented to me, and, in doing so, perhaps answer some of your questions, and perhaps learn a thing or two myself.

Please send me your questions as comments, and I will select one question each week to answer.



Question Number One

"I was at a birth the other day, and the doctor said to my client that there was a recent study done that proves that an early epidural [that is, administered before 4cm] does not lead to a rise in c-sections. What is your opinion on this?"

I think more doulas and women will start to hear about this study, and I think it reflects a dangerous trend. The doctor who quotes recent research seems very with-it and up-to-date - she's done her homework. But let's have a little look at the research in questions:

The study is a systematic review of six studies that included over 15,000 women. Please click here to retrieve it. As you can see, it is a nice little study, I suppose, with one serious flaw that jumps out on first reading.
It states that the ..."review showed no increased risk of caesarean delivery or instrumental vaginal delivery for women receiving early epidural analgesia at cervical dilatation of 3 [c]m or less in comparison with late epidural analgesia." Early epidural analgesia was defined as that administered at 3 cm or less. Late epidural analgesia was not defined, so it could have been administered anywhere from 4 cm well into the pushing phase. Well, when was it? Was it at 4.5? Or was it after an hour and a half of pushing?

The danger is that, the media being the creature it is, someone could simply snip this conclusion, as I have done, and weave a generalization from it. An unsuspecting woman reads the two-sentence generalization and thinks "ahhh, well, that's a relief, I don't have to wait to take my epidural."

Let's look at the reality:
What do we see, as doulas? As I suggest in my book, IF a baby is not optimally positioned (and, by the way, this is also something that we have studied and studied, and we still can't ever really tell when and if a baby is well-positioned, except by watching her  weave successfully down the birth tunnel), and IF a woman takes an epidural early in her labor, and IF the baby's descent could have been helped by a resistant pelvic floor, then this mother and baby could end up with a surgical delivery.

So, in fact, when I see a nice easy birth and:
a mother who has always taken an epidural (and this is her sixth baby and hey! who am I to argue?)
or a mother who always maintained she would ask for pain meds
or a mother who needs meds for another, outstanding reason (sexual abuse being one - we'll get to that another week)
then I have a better feeling about outcome when she decides to take an epidural (even if I know she doesn't really need it).

But when I see a labor that is not going well, for whatever reason: for example, if a woman is having the particular kind of pain that may indicate a poor position, or a woman is undergoing an induction (more about induction coming up too) that looks like it may fail, then I worry about an early epidural, and its effects on labor.

So what can we do about it? "No, little missy, you cannot take the drugs. I as your doula know best"?
Of course not. Maybe there is not really much we can do in the moment. Maybe prenatal education is absolutely paramount. We need to sit with our clients and talk with them about what they are reading, what they understand, what they believe. We need to work with them and open up to them about our own experiences as doulas, and let them know that although a natural birth is definitely simple, it is not usually easy, and that even during labor they will probably have to make choices. And that her choices WILL affect the way her birth unfolds. If she wants a natural birth in a hospital, she will have to work for it. Part of that work will be not accepting pain medication too early in labor.
I know it goes against the review.
But I have evidence that early epidural administration DOES interfere with the normal progress of labor. That evidence comes from my own observation. No studies, no funding, no university degrees. Just women birthing.

Induction Epidemic

As I mention in my book, we still don't know exactly how long a human baby needs to gestate. We don't usually know the exact date of conception, and we have no real understanding of why or how labor starts. Statistics are wonderful tools for proving a point, so I am going to shy away from using them for now. I have read endless discussions on medical professionals' lists about the benefits and risks of 41 week inductions, and I am not at all convinced.

My father is very ill. His body is getting weaker and weaker, and when I was caring for him over New Year's he seemed as frail as a preemie, and weighed about as much. But his mental state is still as sharp as it ever was, his sense of humor as dry, and he had a wonderful New Year's toast with all of us, wishing us all a Happy New Year.

I don't know when he is going to go. It could be in two weeks, it could be in two years. But none of us would think to hasten his departure by giving him some meds that would call on the Angel of Death. Of course, if he were already half gone, we have been ordered by him to let him go. But as it is, we are waiting, trying to stay in touch as much as we can. My mother is there, cooking his favorite food and listening to his favorite music with him, reading him detective stories and generally fussing over him.

As it is at the end of life, so should it be at the beginning. If a woman and her baby are doing well, and all the medical tests show that everything is fine, then there is absolutely no reason that the baby and his mother should be "stimulated" to start labor. I am not arguing that once a woman reaches forty weeks she should be abandoned by her medical caregiver. Certainly, she can have a weekly Non-Stress Test or a Biophysical Profile. But if these tests show that all is well, why are we relying on numbers and averages to make medical decisions?

We had a holiday season recently. The hospitals in our city were packed during the week before Christmas. It wasn't because everyone had been having wild sex at the end of March last year. It was because women, their partners, and their medical caregivers wanted those babies to be born before the holiday, so they decided upon induction rather than waiting and suffering the inconveniences that would result.

A doula is a very useful resource in this situation. She can and should help the parents-to-be understand the advantages and disadvantages of induction, and help them to ask the medical caregivers the right questions. Informed choice is not just a buzzword, it actually means that the patient is informed and can make a choice. The patient should be informed, not just by the doctor who has to go away for Christmas, but also by someone who can inform her that if her cervix is long, closed, and high, and she is a first time mother, and her mother and sisters all carried their babies to 42 weeks, then  she may have a higher risk of ending up in surgery than if she waits a few days and trusts her doctor's backup.

There is an induction epidemic going on. Induction can and does lead to further interventions. If a prostaglandin induction does not stimulate labor, then oxytocin is initiated. Prostaglandin gel, IV oxytocin, and epidural medication can have a bad effect on the fetus, and may lead to emergency cesarean birth. All of these interventions are miracle workers when they are used to save a mother's or a  baby's life. To use them for social reasons is not only bad medicine, it is a sad reflection on our culture and our way of life.