Ask the Doula - the "too-big baby"

A week has gone by already, so quickly. I am involved in many interesting projects, more about them in a few days...
It's Ask the Doula time again!
Please keep sending in your questions. You can add them as comments below, or send your questions to our facebook page, or twitter @montrealdoula.

Today I am going to be looking at the question of cephalo-pelvic disproportion, or the "too-big baby". This mother generously agreed for me to print her question and the response.


Question Number Three 


"I had my first baby three years ago. I am expecting again and I would like to have a doula to accompany me. I am not sure how it will go. My doctor told me that my pelvis is too small to give birth. My first baby was born by cesarean after I was in labor for two days. I had contractions all day on the first day, then by the next morning they were so painful I couldn't even talk. We went to the hospital, where they broke my waters, and then I took an epidural. My baby didn't come out after two hours and they said she was too big. She ended up weighing seven pounds thirteen ounces, and had an Apgar score of 9 and 10. I have a very small pelvis and a narrow pubic arch. Do you think this is a good reason for a cesarean?"

First of all, let's understand how birth stories work. A woman will tell me her story, and it will be just that - her story about what happened to her. It is a story in the first person, about a primal experience she had. I will listen to the details but I will also listen to the tenor, the resonance, of the story.

This story is about a normal labor that somehow went wrong. The first hint is that she labored all day and after 24 hours had contractions "so painful I couldn't even talk." This is normal labor. Mothers will have contractions for a few hours, or a few days, and they will be uncomfortable and even painful. Then the body gets down to work and contractions become so intense that she cannot speak through them. Then she gets to the point where she doesn't even want to speak in between contractions, and this is when the doula knows that the laboring woman is definitely in good labor.

But in this story, the woman was not prepared for the intensity, and she went to the hospital soon after she entered the beginning of active labor. She doesn't say why they broke her waters, but usually it is done because there is a perception that labor isn't moving quickly enough.

In this case, it appears that the breaking of the waters did stimulate labor, and this stimulation increased the intensity of the contractions to the point where the laboring woman decided to take an epidural for pain relief. She was probably quite tired by now, as well, as no one had told her to rest during the night in between the contractions.

The epidural probably helped in terms of her energy, and her body obviously did the work of opening so that she reached the pushing phase. Then what happened? She pushed for two hours. The staff told her the baby was too big and she went to surgery. I cannot extrapolate too much, but here is a possible scenario:

The pelvis is narrow and small. The body made a baby that, in fact, was a perfect size for this pelvis. Her labor was progressing normally and the baby was doing the appropriate moves to navigate through the bones of her mother's body. At a certain point, she had moved her head to a sideways plane so that she could get some leverage to push it down further.

Imagine one of those wooden toys, where the child has to push blocks through different-shaped holes. The child will turn, and turn, and turn the block until it finally pops through. He learned this at birth.

But suddenly, the amniotic fluid drained, and she found her head stuck upon the bone in a awkward position. She still instinctively pushes her head to the other side, to straighten it in order to descend further. As she is doing this difficult work, she feels her mother's helpful body go limp. She has no more help from the outside, just uterine contractions that are pushing her more and more into a position that will be very difficult for her to move from.

The cervix becomes fully dilated, because the body is doing what it should. But the combination of the narrow pelvis, the crooked head, the epidural, and the impatient staff adds up to an unfortunate turn of events.

If she had decided to stay at home longer, until labor was more active, she may have avoided getting her membranes ruptured. If she had a wider pelvis, the baby may not have gotten stuck. If she had a doula by her side, she may have managed to avoid or at least postpone the epidural. If she had not taken the epidural, vertical or forward-leaning positions could have helped the baby come down. If the staff had patiently waited another hour, she may have pushed the baby out.

But we do not know. We really can never know what could have happened, had things been otherwise. But if we agree that we could never know what might have happened, then we have to also admit that we do not know if another baby, perhaps with a slightly smaller head, in a better position, without an epidural, with a doula assisting the mother, could successfully navigate through the birth tunnel and be born vaginally.

My answer? I do not know the reason for your first cesarean. But I do know that you do not have any conditions that definitely preclude your giving birth vaginally. There is a saying: "labour is the best pelvimeter". In layperson's terms, this means that the best way to measure your pelvis is with a baby's head, when you are in labor.

My advice? Hire a doula. Make sure you have a good relationship with your doctor or midwife.Stay positive and open. I wish you the best of luck!

Owning Our Practice

When we are working with such an elemental and mysterious thing as birth, it is often hard to tell where the lines that define ourselves and others can or should be drawn. I was speaking with another very experienced doula the other day who took exception to something I said. I suggested that inexperienced doulas may not be as successful at preventing unnecessary cesareans as a doula who has had years of experience working in a hospital environment with many diverse clients.
She countered, and rightly so, that the essential role of the doula is to offer companionship and respect, and those qualities will triumph, whatever the outcome.

I agree. To a point. Love works wonders. But a combination of things are at play, especially in a busy hospital that may or may not have a sensible approach to natural birth. A younger, less experienced doula may not know quite how to respond when a resident reaches for the amniotomy hook as she is doing a vaginal exam and prepares to do an amniotomy, all without saying anything to the laboring woman. Although we don't like to admit it, it is true that even the presence of a more experienced doula will help doctors to exercise caution. A less experienced doula will not know the policies and protocols of the various hospitals as well as a more experienced one. She will not have built relationships with the medical staff she is working alongside. All these elements can and sometimes do lead to the inexperienced doula accompanying a woman along a very different path than the one they had hoped.

That said, is that not our ultimate mandate? To accompany? To be a companion as the woman makes her journey? If we are beside a woman and her partner as they are becoming parents, and we are there to support, to love and respect, as the woman moves through labor, is that not sufficient?

Yes, if the environment she is birthing in is a sane and healthy one. Definitely. But what if a woman is birthing in an environment where the professionals are overworked, the infrastructure is crumbling, the focus is on risk instead of health, statistics are distributed as freely as narcotics, and the emotional and spiritual side of bringing a child into this world are more or less ignored? Then, possibly, a birthing woman needs more than a companion in love. She needs a watcher, a guardian. Experience, skill, humility, and an open heart are the foundation blocks that a doula can build her practice upon. And one important rule is: never stop learning. When you have a chance to change your mind, change it. When you feel you know enough, know you are wrong. The responsibility is great, the stakes are high. Ego should not take part in the miracle of birth.

A Peek into the Doula's Year

… you are assisting at someone else’s birth. Do good without show or fuss. Facilitate what is happening rather than what you think ought to be happening. If you must take the lead, lead so that the mother is helped, yet still free and in charge. When the baby is born, the mother will rightly say: “We did it ourselves.” Tao Te Ching

January 23 … I make myself comfortable on the couch in the living room … they have the lights on low and there is a sweaty, earthy smell in the air. The cat hovers around my ankles. I hear another contraction coming and going. Its 3 a.m. and I have been here for two hours. In the morning, we will go to the hospital, driving on the highway at dawn. The baby will be born by breakfast time. Everything is good.

March 16 … I am sitting in the Jacuzzi room, kneeling quietly next to the bath as I splash water on her back.

July 3 … She wants to dance during contractions, back and forth across the small room, keeping me moving as she holds my hands.

October 1 … I speak gently to the father-to-be, explaining that her pain is normal and his anxiety is perfectly natural.

December 23 … She calls me at home at 2 a.m. I awaken and answer the phone quietly. She says she is in labor and wants me to come to her. I hear from her voice that she is not ready so I speak to her for a while through a few contractions and suggest that she tries to sleep. She calls me at 7 a.m., after sleeping for four hours. She was woken by stronger contractions and she calls me to find out if it is time to go to the hospital. I reassure her that she is coping very well and I talk her through a couple of contractions over the phone. As she is still able to talk through them, I know that I will be able to start my day as planned. She calls me after lunch to say that she has lost a pinkish mucus plug and that she can no longer speak through contractions. I reassure her that everything is going well. At 9 p.m. her husband calls and I can hear her moaning in the background: they want me to meet them at the hospital. We arrive together and the doctor finds her cervix is seven centimeters dilated. She is given a room and she continues to labor well. Her back is hurting and I use St John’s Wort oil to relieve the pain. Her husband is by her side, letting her know that she is doing a great job. She turns to me and says that she needs pain relief. I tell her that this intensity of pain probably means that the baby is almost here. With her next contraction she starts to push. The nurse comes into the room and notices that she is pushing and calls the doctor. As the doctor arrives, it is clear that the lady is pushing and her baby will be born soon. The doctor greets her patient and as the nurse prepares everything on the delivery cart, there is silence and peace as the woman relaxes in between her contractions. As she gets ready to push again, her husband gently wipes her face as he murmurs words of encouragement. I know that with this contraction, the baby will be born. And he is. The doctor tells her patient to reach down to take her child; as she does, her husband bursts into tears. The nurse helps her to place the baby on her chest and covers them both with a warm blanket. I look at the doctor and we smile at each other, happy with the team effort.

Birth Conspiracy?

I remember seeing a medical student who was attending his first birth. It was a normal, natural hospital birth. The woman was on the bed, her husband was by her side, I was next to him, there was an intern helping with the delivery, a nurse, the physician in charge, and a young medical student. The baby came out, everyone was happy, the new parents were exhilarated and crying, and then the medical student exclaimed loudly: “Look! Look! Look at its little toes! Look! They’re like real toes. They’re just like real toes!”
The attending physician looked at him and whispered: “Philip, get a grip!”, but I was hoping that that simple amazement and wonder would stay with him throughout his career.
For some people, this story may be full of problems and issues. What do I mean by a “normal, natural hospital birth”? Can a woman have a natural birth in a hospital? I remember hearing from an obstetrician that among some women in our city a “natural” birth was when you didn’t wear much makeup when you gave birth. What is a normal birth? If a hospital has a 90% epidural rate, does that mean getting an epidural is normal?
And certainly, we can’t have trained professionals going gaga over newborn’s toes, can we?

We are living in an age when we are terribly concerned with our health, yet it is an age when human life expectancy is at its highest. We worry and fret endlessly about our children, but have difficulty finding time to spend with them. We are living a life that is far from nature, yet we yearn for the “natural” and the “green”. We are so divorced from our own bodies that a surprising number of pregnant women do not know where their cervix is or how a baby is supposed to come out.
In our world, human life has become so complicated that every simple activity has a huge structure built up around it. This structure is built upon a foundation of information supplied by an army of experts. Simple processes such as eating, healing, making love, giving birth, breastfeeding, caring for children, have all become complicated and institutionalized. When a woman decides she wants to have a child, one of the first things she will encounter is the structure we have built up around birth. She will be met with a mountain of information and much of it will be conflicting.
In the birth world everyone wants to have a little piece of the birth experience. The birth practitioner wants a piece of even the most physical and elemental. Here is an example: It is often very tempting to do a vaginal exam. Why? We want to know what’s going on; if the baby is moving down, if the cervix is opening, where the baby’s head is positioned. What most practitioners will not admit is that this intimate physical connection with a woman is important to them: it is an amazing thing, to feel a baby’s head coming down the birth canal! But how often is it really necessary? Does the laboring woman actually want to have so many exams? How many vaginal exams are done for the sake of the birthing woman, and how many are done for the attendant?
The birth practitioner, or any birth “expert”, also wants a little piece of the bigger picture: we want the woman to have a natural birth, with no epidural and no interventions. Or perhaps we want her to have an epidural so that she can be more comfortable. Or we are convinced that surgery will be less risky. Either way, we want to convince her that we know best. In fact, we do know best: we are more educated, we have seen more births, we have seen more pregnant women and we know what to do.
Or do we?
The Birth Conspiracy is this: It is an understanding, created by all of us, that we cannot function without experts. We cannot give birth without birth experts. We cannot labor without assistance, without classes and checklists. We cannot make our own decisions, or accept consequences for our own actions. It is a way we can avoid responsibility for our lives. Those of us who are experts want and need to control the process. It is very hard to sit on your hands and wait while a woman labors. It is much easier to interfere, to preach, to suggest, and to control.

Interested? You can order your copy of The Birth Conspiracy soon - watch this space!