Sunday, November 9, 2008

Back into doula-ing

I haven't been updating this like I want to! I know no one reads a blog that's only updated once every two months (although if you use a feed aggregator - I use Google Reader - then you might see entries from me pop up from time to time). I'm going to try to update at least once a week for the rest of the semester, and see how that goes.

I think that will be helped greatly by the fact that I have started working as a doula again! It's been too long since I was at births. I am volunteering for a hospital-based doula program, which is fabulous - that's how I started working as a doula. I know it so well and enjoy it so much. I believe being a hospital-based public health-focused doula calls on some different skills from those of a private doula. In many situations, you're playing a mix of traditional doula, social worker, and friend - the kind of friend a lot of birthing women do not have.

Last night was my "mentor birth" with a doula who has already been volunteering there for a while, so I could learn the ropes. We just went in there hoping to find someone to work with, and did. My mentor doula partner could only stay for about six hours; it was great to have her there before I started flying solo in a new hospital. Every labor and delivery floor has its layout, quirks, and personality for you to learn.

The labor I attended gave me a lot of food for thought, especially being my first one after an extended break from doula-ing. As I closed my eyes for my catnaps throughout the night, I thought about what I wanted to post today. I wanted to share some meditations about two things I wish all women might do at their births:

First, not to engage in the doctor's "nudging" conversations. "Nudging" conversations go like this:

DOCTOR: [right after a cervical exam] We-ell, you're at 5 now, which is good. We might want to think about breaking your water soon to get things moving a little bit.

WOMAN: [usually this is the first she's ever heard of this concept] What's that?

DOCTOR: It's when we just take a little hook and break your water. It helps bring the baby down and it can speed things up.

WOMAN: Will it hurt?

DOCTOR: No, you don't have any nerve endings in your bag of water. I'll just take this hook [shows hook] and just slide it up there. You'll just feel fluid. It just helps speed things up a little, it can help you get this over with quicker. What do you think about that, could I do that for you?

WOMAN: [overwhelmed by all the information] So, it's going to help?

DOCTOR: That's what we're hoping, there's no guarantees but it can help move things along, you're just at a place where we want to make sure your labor keeps progressing and we don't want things to slow down. I'll just slide it right up there and break your water, it won't hurt.

WOMAN: Yeah, I guess.

DOCTOR: Okay? Can we do that now? It's totally up to you.

WOMAN: No, that's fine, I guess we can do that now.

DOCTOR: Okay, wonderful! I'm just going to sit on the edge of the bed right here...

And so forth. The mom is given the sense of control over the decision, and lots of information, but not the information (risks and benefits) that she might really need, and her "control" option is often emphasized late in the game when she's already seemingly decided in favor. If this sounds like a conversation that you might have with a small child that you're trying to convince to do something, you're not far off the mark. Many women I work with come in with almost zero information about childbirth. They haven't taken classes; they don't know what a cervix is. Doctors know this; I'm not saying they like to have uninformed patients, because I want to believe the best of OBs (I really do), but they are not above (even subconsciously) using the information deficit to their advantage. Even if I can offer the mom and her partner some extra information on risks and benefits, the conversation is usually over before I could have a quiet talk with them alone.

However, this doesn't just apply to the childbirth unedated; even people who are very prepared can succumb easily to the nudge. You're exhausted and a little scared and you just want things to be over with. Whether or not they're going to move your labor in the direction you want, it's easy to find yourself agreeing to something before you've had a chance to pause.

However, there are ways to be un-nudgeable and give yourself space and time to think and talk over your options. One great way is just to say "I'm not sure, let me think about it" to everything. Ask all the questions you want as they explain, but keep saying "I'm not sure" until they've given their final spiel about how it's up to you and left. They might throw some scary stuff in there - heart rate dipping, labor slowing, etc. Hear all that, and then let them leave and think and talk it over. If it's a true emergency, you won't be given any choice; if you're being offered an option, it's because it truly is an option!

The second is the role of fear. I loved this post about fear and childbirth. I have worked with women who are just terrified of birth. No one has ever helped them work through the fear that our society instills about birth so they can embrace it. It's incredibly sad to see what should be a happy experience be a horrified ordeal. Every woman should receive positive childbirth ed.

Some of these women do end up embracing some of the more frightening aspects of technology (elective c-section anyone?). Others, though, become the least nudgeable women I've ever seen. They are paralyzed with fear of doing anything; they consent to nothing. It's one way to have a natural labor, but it's a pretty miserable way! It's also a very difficult way to achieve any kind of progress because they are so tense and frightened, they can't relax enough to dilate. It often leads to c-section and a very challenging experience all around. I feel really deeply for those women.

So those are my meditations for the day, on nudging and fear. Not a very coherent theme, but I wanted to get those down. And one last observation, extremely simple and to the point: inductions can be so difficult and should be avoided at all costs.

If I could wave my magic wand and change one thing, it would be hard to choose, but it might be the willingness of OBs to induce. Reasons not to induce, in my book: tired of being pregnant, "large baby" (uh-huh), past dates (by four days), convenience, etc. etc.

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