Meconium Happens

The more I live this life, the more I am convinced that the deal is, it is not what happens to you that matters so much, it's how you accept it (or not). I have been to births that have been really challenging and tough, where the woman accepts the labor and is thrilled with the whole experience. I have seen other women fight against labor and birth, one contraction at a time.

Today is December 6, 2020. A day like any other. Except not: it's the anniversary of the day when 14 women were killed by an armed killer.

It's a day when my friend had to go back into hospital. It's a day when thousands of people died from Covid-19.

It's a day when we have to, as always, take the joy from every moment and cherish it. And even when we are full of joy, and all comfy in our enlightenment and entitlement, shit will happen. Meconium does happen. A baby can suffer some small slight and poop. Or a baby can get their cord squeezed so much they poop a lot. Things break down, things break. People break. 

But where there's rupture, there's repair. A body's urge is to health, just as a plant moves towards the light. In the same way, the knowledge of women has always been towards healing. 

We can't do anything to bring those women back to life. But we can speak out against violence every single day. And, unfortunately, in my field (haha no, not in my cafe...in my real field which is maternity care), violence against women is rampant, ugly, and expected. 

What can be done? Well, one thing that's happening is that pregnant women are rising up and saying "No more violence! No more treating me like I'm a child, that I don't have feelings, that I don't know my own body. No more speaking about me as though I'm not present. No more making decisions about my body without my consent. No more doing things to my body without my consent. No more lying to me!" And how are these women doing that? By withdrawing from the hospital system. They are giving birth on their own or with Traditional Birth Companions. 

Another thing that is happening is that doulas are continuing to support women who choose to give birth in the hospital. Or, more importantly, those women who don't actually have the choice and have to give birth in the hospital. Especially these days, it's hard to be a doula. Many hospitals have taken away the birthing woman's right to support by insisting that she choose between her partner and her doula. So doulas are providing companionship and support virtually. 

Medical staff in hospitals in today's world are stressed. They're overworked, tired, and they have all the same concerns on their minds as you or I. Suicide rates are higher for physicians than for the general population, and higher for female doctors than males. The medical system isn't working for anyone.

What can a doula do to relieve everyone's symptoms? Let me be clear: when a doula works to facilitate a mother feeling empowered in a situation where her power can be taken away from her at any minute, we are not talking about getting at the root of the problem. If a birth is an undisturbed birth in a place where the birthing woman is comfortable, safe, and respected, then the doula can do the work of being a doula: easing labour, providing encouragement, seeing to the birthing woman and her family's needs. But if a birth is taking place in an environment where the go-to routine is medication, management and directives then the doula can only provide bandaid measures within a strict and abusive system.

And these bandaid measures can work! Any number of women leave the hospital with their babies feeling joyful, even ecstatic, and satisfied with their care. But a huge number of women leave the hospital hurting.

Is it time to finally step away from an abusive system? What happens to a woman when she has a vision of a natural, normal birth and she arrives at the hospital and things start to go haywire? Is it possible to convince women to stay at home, at least until they are in active labor? What about the woman who feels every contraction, from the very beginning, like torture; the woman who can't separate her labor contractions from an abuse she experienced years ago? What is the role of the doula through this seismic change? What about midwives? Why are midwives still using the words "should" and "allow" when they speak about birth? 

Is it time to Rise Up?

Losing Your Self

Back in the fall, I went to a birth. It was the first birth I'd been to in a long time. It was wonderful! But it was very different from how I imagined it would be.

I always love the feeling that I am doing exactly what I was meant to do: accompany women during childbirth. The most important lesson about birth is that it is very much like life: you can't really plan for it. Meconium happens. Stuff gets broken. People get lost. Suddenly you turn a corner and there is the most beautiful sunset you've ever seen.

Here is a picture of an obstetrician waiting for an unsuspecting pregnant woman. She is being pulled along to the birthing room by her husband...dropping her slipper like Cinderella...he is rushing to punch the clock ... I'm late! I'm late!

The doctor holds a limp pair of forceps in his hand. He is going to get this baby out, for once and for all!!!

Of course, birth doesn't usually happen according to our plans, or according to anyone's schedule or hourly rate. Babies come when they want, or when they need to leave their mother's womb, or when the womb needs to expel them. Who knows. But they don't generally show up when we plan for them to.

And then when they do, the birth unfolds in a different way from what people had been expecting or planning. Which is why I still don't believe that birth plans are useful. Not because birth shouldn't be thought about and considered deeply, that choices shouldn't be made about where you want to give birth and with which people around you. But because the unfolding of your birth experience, of any birth experience, is unpredictable and can't - shouldn't - be pinned down. Because if you try to capture it with a plan, you could miss out on something extraordinary that you hadn't thought about, that couldn't be contained by your plan.

So, what does that mean for us attendants? How do we plan our days and our lives? 

Birth attendants are often on call day and night. Doulas may be on call for months at a time, unless they structure their work effectively by creating a doula collective which involves sharing care. But most doula clients want the continuity of care that means that one doula is always available. So there go your plans for family events, sleep, trips....

But in a deeper sense, when you are actually attending a birth, when the labouring woman is there deeply in the process of birth, then what? Are you thinking about what groceries you are going to buy tomorrow? No, you are with the labouring woman. You are providing support for her and her family, her partner, whomever. Even if you are sitting in a comfy chair knitting: your intention, your senses, your compassion, your heart and all of your focus are bound up with the birth process and the safe place you are creating for the newborn family to move through.

And then you lose yourself. You forget about your worries, strengths, failures, envies, moods. Your only task is to serve birth. You are serving the woman as she moves through her experience of birth, as she becomes a mother. And are you the most important person in the room? Is the obstetrician the buck upon which stuff stops? Of course not. The most important people in the birth room are: the mother and the baby. And how they are treated by everyone else is the most important aspect of the whole process. So, the less we all worry about ourselves, and the more we focus, truly focus, upon the family-to-be, the better off everyone will be in the end. Losing yourself is just the beginning!

Induction Epidemic

"Unless conception occurred via in vitro fertilization, techniques used for obstetric dating are accurate to 3 to 5 days if applied in the first trimester, and only to 1 to 2 weeks subsequently. Estimates of fetal weight are accurate only to 15% to 20%. Even small discrepancies of 1 or 2 weeks between estimated and actual gestational age or 100 to 200g difference in birth weight may have implications for survival and long-term morbidity. Also, fetal weight can be misleading if there has been intrauterine growth restriction, and outcomes may be less predictable. These uncertainties underscore the importance of not making firm commitments about withholding or providing resuscitation until you have the opportunity to examine the baby after birth."
Textbook of Neonatal Resuscitation, 6th Edition, Ed J. Kattwinkel, American Academy of Pediatrics and American Heart Association (2011), p. 288

We cannot know when a person is supposed to die; neither can we predict exactly when a baby is to be born.

We have some numbers to play with and we do our best under the circumstances. Everyone knows that babies take nine months to grow in their mothers’ wombs. In the Jewish Talmud, it is stated that pregnancy should last 270 days from conception to birth. Modern Western medicine counts 40 weeks from the date of the last normal menstrual period, which gives a baby 38 weeks to mature, if his mother conceived fourteen days after her period. Many midwives will look carefully at a woman’s menstrual cycle, and will try to calculate together with the woman when she may have conceived. Based on these dates, she will give an estimate of a two or three week period during which the woman is likely to give birth. Some women give birth before their due dates, a few exactly on the day, and many give birth up to two or even three weeks after the date has passed. The tendency to carry a baby for over 41 weeks appears to run in families and can sometimes be predicted if a woman has carried her first child “post dates”.

One thing is for sure, babies do come out eventually. However, it is possible that certain risks increase the longer a baby stays in the womb. The placenta may diminish in optimal function after about 42 weeks, putting the fetus at risk for hypoxia. Babies born after 41 weeks often have a higher incidence of meconium in the amniotic fluid, which puts them at higher risk of meconium aspiration. Babies keep growing, so a 42-week baby may have a slightly larger head than she did at 38 weeks, thus making it a little harder for her mother to push her out.  Modern medicine tries to diminish these risks by making sure a baby is born on or around the estimated date of delivery, or the due date. There is a lot of controversy about this reasoning, and rightly so. The due date is rather arbitrary. No one really knows when the baby was conceived, and even if they do analyze various ultrasounds, we can still never predict which babies will want to stay in the womb for longer. Occasionally there is a real problem with a baby which prevents the labor from starting spontaneously. This is very rare and does not justify the high induction rates we are seeing.

On

Why are we concerned about chemical inductions? Our main concern is that because chemical labor induction creates very strong, painful and frequent contractions whose character is different from the contractions produced by the woman’s own body, there is an increase in epidural requests. Once she has requested an epidural, the risk of an instrumental or surgical birth increases. Our next concern is whether the woman’s body is ready for a chemical induction. If it is not, then all the chemical and natural assistance in the world will not convince her cervix to open and she may labor for days and end up in surgery. 

 

Let us first have a look at some statistics, remembering that these numbers can be stretched and manipulated just like the perineum during birth. A recent study examined the correlation between labor induction and cesarean section. It looked at a reasonably small group of women (just over 1200) who were at 41 weeks of pregnancy. About half of these women went into labor spontaneously, and the other half was induced. The half who went into labor on their own had a 14% c-section rate, while the rate for the other half was 19%. The increased rate was due to an increase in c-sections performed for “failure to progress”, which was “diagnosed and cesarean delivery performed when cervical dilatation or fetal descent ceased for 2 to 4 hours despite adequate uterine activity”. However, the researchers concluded that the increase was not due to the labor induction “per se”, but rather due to “nulliparity, advanced gestational age, undilated cervix prior to labor, and epidural analgesia”.[i]

It seems to me that if we look at these figures with open eyes we can see that, in fact, induction is definitely an important player in the rise in c-section rates, even if we split hairs and suggest that it is not the main cause. Nulliparity certainly has an effect, and every doula knows that a first-time mother is going to be more of a challenge than a mother who has already gone through the experience. When a first-time mother experiences the contractions produced by synthetic oxytocin, she is much more likely to request an epidural than an experienced mother who knows that labor will, in fact, end and her child will be in her arms soon enough.

A woman with a closed, hard and posterior cervix is not an acceptable candidate for chemical induction. The rates of surgical delivery increase with a lower Bishop’s score. The following chart shows how we calculate this important score.

       

Score	Dilatation	Effacement	Station	Position	Consistency
0	0	<40%	-3	posterior	firm
1	1-2 cm	40-50%	-2	mid	moderately firm
2	3-4 cm	60-70%	-1,0	anterior	soft
3	5+ cm	80%+	+1,+2	anterior	soft

A point is added to the score for each of the following:
   1. Preeclampsia
   2. Each prior vaginal delivery

A point is subtracted from the score for:
   1. Postdates pregnancy
   2. Nulliparity
   3. Premature or prolonged rupture of membranes

The scoring is done according to the physician’s or midwife’s estimation of the cervix, and extra points are added or subtracted. Any score under 6 usually means that the cervix is not ready for induction and cervical “ripening” is initiated using prostaglandins. A score above 6 is encouraging and often means that a woman will be successfully induced and has more chance of a vaginal delivery. Induction leads to a higher epidural rate; epidurals lead to higher c-section rates: it is undeniable that labor induction can increase the risk of a c-section.

How can the doula help? We do not want to alienate the women we are working with. If she is happy with an induction and understands the possible implications, then it is the doula’s job to support her. We do not want to turn a woman against her doctor. If a woman has chosen a doctor and is convinced she has made the right choice, then the doula must not interfere with that relationship. It is a woman’s right to ask questions of her doctor, and she can say no to the doctor’s suggestions, but it is not the doula’s responsibility to do so. We do not want a woman to feel guilty about listening to her doctor. We often find ourselves in the following situation: the client is reasonably happy with her doctor, who has said that she almost never induces before 41 weeks. The woman has just passed forty-one weeks and the doctor is not working on the upcoming weekend. She has offered an induction on the Thursday, so that she can be at the birth. Both the baby and the mother are fine on the one hand, but on the other hand, the mother is getting very tired of being pregnant and her in-laws are calling every five minutes. The client calls her doula in tears. What can happen during this call is what we call a “learning moment”. That is, the doula and her client discuss all the issues and go over all the options and implications: The doctor has confirmed that the baby is doing well. This is an opportunity for the woman to take the process into her own hands and refuse a medically unnecessary induction. She can wait until after the weekend, when she and her doctor can make a decision. Often, in this type of situation, a woman will spontaneously go into labor.

More serious is the situation where there is a perceived risk to the baby. In this situation, it is up to the doula to support her client and refrain from bringing doubts, research and opinions into the equation. If a doctor is convinced that, for example, the fluid is dangerously low, it is not the right time for a doula to suggest that perhaps this is physiologically normal or that the ultrasound technician could not see behind the fetus. This is the time for the doula to support her client wholeheartedly.

This is an example of the fine art of being a doula. We are not midwives, working from a rooted trust in the healthy efficiency of the female body. We are not physicians, sensitive to flaws and malfunctions in the labor process. We are there to support a woman through the labor process, as she sees fit, without judging, without voicing our opinion. Here is a story about an induction where the doula was very active in the whole process. This woman’s first labor had been chemically induced and she was hoping to avoid it the second time around.

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[i] Obstet Gynecol 2001;97:911-915