Ma Doula

by Stephanie Sorensen

  We met at the hospital on B-day. We went over her options for pain meds and some of her wishes. She didn’t want to be asked repeatedly about her pain level. She had done her homework and knew she could ask if she wanted something for pain. She wanted to try the tub, birth ball, and different positions first. She definitely did not want male providers during the birth, if at all possible, and no extra interns or students milling about. She absolutely didn’t feel comfortable having to deal with crowds of people.

  It was Sunday evening and the plan was to use a prostaglandin cervical “ripener” called Cervidil or dinoprostone, which is inserted into the cervix, sits there for twelve hours while the mother sleeps, hopefully, and prepares the uterus for further induction in the morning. Occasionally, the Cervadil alone will initiate labor. I had encouraged Rhoda to eat a good supper before going to the hospital because, I cautioned, she might not be able to eat much once in active labor. Each hospital I work in has a slightly different protocol for this.

  Her partner took her out for supper and they arrived in a great mood, ready to welcome their baby into the world. I had brought two of my favorite movies, which we settled down to watch together after the Cervidil was in place. Rhoda had been concerned that the insertion of the Cervidil would hurt and was relieved that it didn’t.

  We watched Birth Story, which also helped set the mood in the room. The DVD has a “down-on-the-farm” feel—literally. It’s about Ina May Gaskin and The Farm midwives in Tennessee. This initiated several questions about the use of imagery during labor and we talked about several aspects of that after the video. Then we watched Everybody Loves . . . Babies, which brought up lots of observations about parenting in other cultures and models of bonding.

  Three hours later, Rhoda was ready to sleep. The nurse brought in some juice for her and a pile of bedding for her partner so he could fold out the lounge chair/cot next to the bed. I lived very close to the hospital so I suggested I go home and sleep, too, assuring them I could return within ten minutes should they want me to come back; otherwise, I would be there when they talked with the doctors in the morning about the next plan of action. They agreed and settled in for the night.

  I didn’t hear anything during the night and both of them were still sound asleep when I arrived the next morning. They were up, though, when the doctors came at 9:00 a.m. Rhoda’s OB checked her cervix, which was three centimeters dilated. Great news! They suggested augmenting the labor with a small dose of Pitocin to encourage contractions that, in turn, would hopefully help her to fully dilate. The couple agreed and the nurse unplugged the monitors to let Rhoda shower and walk around for a while. Before the doctors left I asked if she could eat until she was in active labor. They readily agreed so we ordered a big breakfast. She told me she wasn’t sure she could eat and was afraid that she would throw up later if she did, but I reminded her that it could be an all-day or even an all-day-and-all-night process and that she needed the calories and natural sugars on board to do it. I assured her we were prepared if she did feel her breakfast coming back up and showed her the drawer by the bed stocked with Chux pads and the little disposable “hats” for “returning” meals. I laughed and told her we were very used to it and that after you are a mother it doesn’t bother you as much as before.

  I opened the curtains to a beautiful sunny morning. Her breakfast tray was delivered and Rhoda tucked in. I encouraged her partner to get some breakfast in the cafeteria. He hesitated until I assured him that he had plenty of time and wouldn’t miss the birth even if he was gone an hour.

  The nurse started the Pitocin at the lowest possible dose. Baby’s fetal heart tones sounded great on the monitors and Rhoda was quite rested and feeling well. The monitor picked up some contractions but not strong enough for Rhoda to feel. Throughout the morning the couple rested, walked, and she sat on the birth ball. She ordered lunch at noon.

  The Pitocin was increased and by 2:00 p.m. Rhoda was having rushes every five minutes and had dilated to four centimeters. I asked the nurse for a dilation chart and went over it with the couple. We talked about imagining opening up and I told them how I had seen it help and knew it helped my own births. By evening we were working together to breathe through the rushes, which were coming every three minutes and getting stronger. Before her doctor left at the end of her shift, she checked Rhoda again. Four centimeters. This was discouraging for Rhoda but I explained that induction is not the same as natural labor and often takes longer.

  I assured her that she was holding up well and her baby still sounded good, that there was no need to do anything differently. The doctors were not in any rush. I explained that it is far better to go slowly because it gives the baby’s head plenty of time to mold and this slowly stretches the birth canal, rather than tearing it from going too fast. By just reminding the couple that their birth was going really well, they could relax and try to rest another night. Again I went home to sleep. The phone didn’t ring all night.

  By the time I returned in the morning, the nurse was checking her once again—four centimeters. She explained that they really didn’t want to break her water until the baby was a little further down in her pelvis. It was still early. We took turns eating and walking with Rhoda.

  Around noon, two doctors came in to say that although the baby still sounded good, they didn’t feel that the Pitocin was doing much and they wanted to see her dilating better. They suggested that she rest a while and offered some fentanyl or morphine to take the edge off the pain and give her a break since she didn’t sleep much during the night. Rhoda agreed and was sound asleep in no time.

  She was almost six centimeters when she woke up. Her water had broken on its own. But by evening the doctors once again gathered to talk to the couple. First they explained that although the baby still sounded good, they were afraid that Rhoda’s uterus would become tired, and if labor went on much longer it might be more prone to hemorrhage after birth.

  They had checked her when they first entered the room and her cervix was back down to five centimeters and swollen. Even though the water bag was now out of the way, the baby had not budged at all, possibly because the cervix/uterus was tired or that the baby was still so far up that the cervix didn’t have the baby’s hard head to dilate against, which we expected it to be doing by then. They offered a Cesarean section, explaining that she could wait another two hours or ten hours, but she might still end up with a C-section. Rhoda and her partner asked for a couple of hours to think about it and the doctors left.

  Rhoda tried to figure out what she was “doing wrong” and I explained that she was not doing anything at all wrong and that we don’t always have control over our births. She wanted to know if she should try imagery, or walking more, or lunges, or “maybe we can just go home and come back next week?”

  I offered to leave the room so they could talk but they both wanted me to stay. Then it occurred to me that perhaps they were totally in the dark about what happens during a C-section so I asked them if they wanted me to explain. They both nodded.

  I told them that the operating room was not much bigger than the room they were in, but it also had a warmer for the baby and two NRP nurses waiting nearby to help their baby breathe if he needed it. I explained that only one in about 1,000 babies will actually need neonatal resuscitation and some just need suctioning and stimulation to get going. I explained that the OR would be bright and that she would get an epidural but would be awake the whole time, which surprised her very much. She just assumed she would be “knocked out” and the baby forced out somehow.

  I assured them that her partner would be sitting by her head and be able to hold her hand, and that I would be on the same side of a big sterile drape and would tell her everything that was going on and what to expect. I described the “bikini” cut, that the incision would be low on her tummy in the fold of skin above her pubic bone.

  She would have two doctors, one on eac
h side of her stomach, two anesthesiologists, several nurses floating around the room, another one at the instrument table and possibly a resident doctor or two. (We actually managed to avoid having any men at this birth, which I had forgotten we had requested earlier. She would not have noticed by then, but I was touched that they had honored her wishes.)

  I told her that it usually only takes about twenty-five minutes or less from when they start before they lift the baby out and get him right to the warmer. Often the dad can go over there with him and touch his baby and take pictures before bringing him over to mom. She could hold him and talk to him then if he was breathing well and didn’t need any help and she could even try nursing. Then she would be sewn up, starting with the uterus, then the surrounding muscles, and lastly the outer skin would be stapled shut.

  She and Baby would go to the recovery room together, probably in the same bed with her holding him. She would be there about two hours before going to her room on the postpartum floor, where dad could spend the night and their baby could room-in, and she could finally eat and celebrate his birth.

  I went on to say she would be in the hospital three or four days and have time to rest and recuperate. I explained that it is a longer ­recovery than a vaginal birth and that she should ask her family and friends for help during the first three to four weeks at least.

  I realized that by demystifying the entire surgery it had become a choice they were willing to make. She asked if she could first meet the doctor who would do the surgery. She wanted to be okay with the new doctor. The nurse arranged for the doctor to come in, who was also a woman, and they clicked immediately.

  When it was over, Rhoda couldn’t believe how fast it went or that she was already holding her baby. Rhoda was a very petite Latina señora, so I was not surprised that her hijo muy guapo (very handsome son) was just under six pounds. The moment the doctor lifted him up, head first, she said out loud, “Oh, so you were trying to come down forehead first!”

  It is called a brow presentation, which explained why the cervix didn’t have anything hard to dilate against and also why he remained too far up in her pelvis. He wasn’t in a total face and flexed neck presentation, but it was obvious he was looking up, basically, at the start of his descent. His face and forehead were very swollen and the front of his head had tried to mold, but the back of his head had not even begun to. So we had our answers about what was going on.

  I always marvel at how nature does and also does not do things according to any script. The last time I had seen anything like this birth was almost thirty years ago, when I was called late one night to translate in the labor and delivery department of a big public hospital in St. Paul. A Hmong family was having their first baby, who was presenting face first. The family did not like the idea of an operation at all. They had emigrated only a year earlier from Laos and had their own set of beliefs surrounding birth and death and bad spirits that might enter a body once it is cut open. And this was a pregnant body, besides. No, they would not okay a C-section, which the doctors were recommending and hoped I would talk them into. The mother-in-law was pacing around the room when I arrived. I listened for a minute and realized she was basically saying, “Let her die. No uah-pi (operation). We will get him another too-paw-nia chia (wife).”

  The first thing I did was have Grandma removed. The poor girl was terrified that she was dying! And that they were going to let her. I assured her that she had some options and that she didn’t need to worry. The dad was just as terrified as she was. I explained that the baby was coming down okay, though his face would look funny and swollen for a while but it should be fine after a few days.

  They had two options: continue with a vaginal birth, though that might not be easy, or go with a C-section. I knew they couldn’t go against their elders’ wishes and had absolutely no recourse there, but I explained that they did have a say in our country and we would support them. They both said they wanted to try a vaginal birth, though the doctors had hoped I would simply talk them into surgery. I couldn’t. I knew that the entire clan had been called together and consulted already and their answer had been “no.” I also didn’t believe that her life was in imminent danger so I didn’t go into my “take charge” mode and try to scare them further. I didn’t tell the doctors that I tried my best to talk them into a C-section but I simply said they were going for a vaginal birth and that they understood the implications. I told the couple that she wouldn’t die, though she might have in the primitive conditions back in Laos. I tried to help them feel that the doctors really were on their side and wanted to help them. I don’t believe the doctors had ever said she could die if she didn’t have a C-section. They just strongly suggested that it was a better route with a first baby and the grandmother took off from there. She gave birth to their baby shortly after that and it went quite well.

  That was decades earlier and this little guy had tried the same thing. I couldn’t help but wonder if it would not have shown up on a late ultrasound in Rhoda’s case, which she was having often anyway because of the earlier tachycardia episodes. It was also a bit curious that with all of the internal exams no one picked up on the different ­alignment of the baby’s head sutures, or even feel the nose, but I could only wonder to myself.

  I went back for a postpartum visit the next day and found Rhoda walking a bit stiffly around her room, but ecstatic. She was just happy that her baby boy was here and that she felt as well as she did. The C-section was definitely not as bad as she had imagined. I gave her a (very gentle) hug and told her how very proud we all were of her. I reminded her that she had done the very best she could and was an amazing and strong lady.

  “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!’”

  ~Lao Tzu, father of Chinese Taoism, from Tao Te Ching: The Way of All Life, written in the sixth century B.C.E.

  Chapter 19: Doula as Gatekeeper

  Midwife: “I would like to check to see if you have dilated.”

  Vietnamese interpreter: “Tôi muốn xem tử cung bạn đã giãn chưa.”

  Midwife: “Is that okay?”

  Interpreter: “Có được không?”

  My client, Khou, only spoke Vietnamese. She was a beautiful first-time mom whose water broke two days earlier but had just called me.

  Midwife: “Now, put your heels together and let your knees fall back.”

  Interpreter: “Bây giờ, đặt gót chân của bạn với nhau và để hãy thả lỏng đầu gối.”

  Midwife: “You can relax. That’s better.”

  Interpreter: “Đừng lo, đúng rồi.”

  Midwife: “Now you will feel my touch.”

  Interpreter: “Bây giờ bạn sẽ cảm thấy tay tôi.”

  I could only guess that she was either expecting labor to start with contractions first, or a huge gush. A small tear high up in the bag of water can drip like a leaky faucet and was obviously not noteworthy to this mama. As soon as she called me I insisted on meeting her at the hospital and asked her to let her midwife know before she left the house.

  Midwife: “Now I want to put this speculum inside to look.” She held up the speculum.

  Interpreter: “Bây giờ tôi muốn đặt mỏ vịt này bên trong để xem.”

  Midwife: “Sorry it’s cold.”

  Interpreter: “Sẽ lạnh một chút.”

  Midwife: “I will first test and see if this is amniotic fluid; this won’t hurt.”

  Interpreter: “Đầu tiên tôi sẽ xem đây có phải nước ối không; nó sẽ không đau đâu.”

  This little exchange would have been fine and dandy except for the fact tha
t the agency sent a male interpreter that night. I couldn’t believe what I was hearing.

  Midwife: “All done.”

  Interpreter: “Xong rồi!”

  Midwife: “But your water has broken. It seems that it started two days ago.”

  Interpreter: “Nhưng bạn đã vỡ nước ối. Có vẻ như nó bắt đầu từ 2 ngày trước.”

  Midwife: “There is some concern that labor hasn’t started and we want to avoid an infection.”

  Interpreter: “Tôi lo rằng bạn chưa lâm bồn và chúng tôi muốn phòng ngừa nhiễm trùng . . .”

  When he first walked into the room I had leaped off of my perch on a little exam stool by Khou’s bed, looked straight at him and said, “You and I will go behind that curtain by the door and you can translate from there!” as I ushered him away from the bedside.

  Midwife: “So would it be okay if we started labor with something that will soften the cervix tonight?”

  Interpreter: “Chúng ta có thể bắt đầu chuẩn bị sinh với cái gì đó làm cho tử cung mềm hơn tối nay có được không?”

  Midwife: “And hopefully get things going in the morning?”

  Interpreter: “Và hy vọng có thể bắt đầu vào buổi sáng?”

  There was no way I would have him gawking at Khou lying there. I couldn’t believe they sent him!

  Midwife: “Yes? Okay. I am going to put some medicine into your vagina and into the cervix.”

  Interpreter: “Có? Okay. Tôi sẽ đặt một số thuốc vào âm đạo của bạn và vào cổ tử cung.”