"To sleep/Perchance to dream"

I love the drive from a client’s house to the hospital. I’m following my clients, watching the labouring woman’s hand reach up to the roof of the car during each contraction. For me, it’s an in-between time of quiet watchfulness, similar to that “out of time” feeling I remember while feeding a baby in the middle of the night.

Last night, we had a long drive from Surrey to Burnaby General. So, I turned on the radio to CBC Ideas and heard an amazing piece by Jeff Warren called "While You Were Out" about the changes in sleep patterns over the last three hundred years.

References to “first sleep” are present in Renaissance and pre-industrial writings. Only now are researchers discovering that our biological sleep pattern has two main cycles, “first sleep” and “second sleep,” with a two hour intermediary trance-like period, “the watch.”

After sunset, the family would head to the communal sleep space. There would be a quiet period of 1-2 hours rest in the dark, followed by “first sleep,” a deep rejuvenating state. This long wave sleep state would increase the levels of prolactin (ah, the breastfeeding hormone!) After 4-5 hours, people would enter an altered state of consciousness, induced by these high prolactin levels. Any breastfeeding mum knows the timeless trancelike effect produced by high prolactin levels - patient, waiting. In this period, people would traditionally pray, muse on the day’s events, or quietly make love, while listening to the natural sounds around them. Later, “second sleep” would come, full of REM sleep and dreams. They would all wake at sunrise.

This sounds so much like a typical night with a new baby. Hmmm... Rather than seeing the postpartum sleep pattern as unnatural, perhaps we should see this as our return to our natural biological state. Sleeping alone in a room devoid of sensory input seems to be an unnatural state for humans. Our North American need to mold our babies into beings who can sleep alone for long uninterrupted periods is, in fact, altering the delicate hormonal and chemical balance in our bodies.

So, have a quick read of the article, “The Cultural Biology of Sleep,” before delving into Carol Worthman’s research papers, which include “The Ecology of Human Sleep.” You may find some food for thought during “the watch.”

778-883-9851...vancouverdoula@gmail.com

All my previous clients have the correct spelling of my name "Jacquie Munro" and my email address. But doctors who've run out of my brochures resort to scribbling down my name for their clients... Oh, dear, just look what happens then...

Yes, I think it's time to send out more brochures when:
1) Clients try to google my name but have been given the wrong spelling,
2) A client sees an article about me, phones up the newspaper, then has to convince the editor to release my phone number (very resourceful, but could have resulted in the end of the search),
3) Old-school clients look for me in a phone book (no, it's not there!), and poor Jack Munro or Jackie Munroe, etc., still get the odd message about "wanting a doula" on their voicemail, or
4) One potential client googles "Adoula" thinking it's my name...nope...my name is not Adoula Munro.

People can always find me by googling "Vancouver" and "doula", since I'm "Vancouver Doula". Plus my email address is vancouverdoula@gmail.com.

But I still think I'll head down to the printers for some more moo cards...so the midwives and docs can still hand out my cards with the pretty photos...

- Jacquie Munro, Vancouver Doula

“Come out of the circle of time/And into the circle of love” - Rumi

In the past, it was the partner’s job, as coach, to time each contraction with a stopwatch. I still have my old list of “...8:27...8:39...8:45...8:54...”from my first labour in 1983. The fixation on time has continued. Now there’s even a program that you can download to your Blackberry which will graph your contractions!

In contrast, I encourage my clients to let go of actively timing contractions at the beginning of the labour process. I think timing contractions is almost too simplistic a gauge of how labour is progressing. It makes you focus on an external reality and lose touch with your inner rhythm, your inner knowledge. It can also make you fixate on how long things have been continuing which, in turn, can lead to frustration or impatience.

Take me for example. There I was, waiting for my first labour to start. I was 10 days overdue. On paper, it looked like I had been in labour for a week. Contractions were every three minutes - sixty seconds long. I thought I was going through the longest labour on record. But I was still able to walk and talk through each “contraction.” I was really just having prelabour tightenings. But my fixation on timing had made me exhausted and mentally drained even before the true labour began. If I’d been able to talk with someone a few times a day during that last week, someone who understood the logic of the body and the rhythm of labour, I might have been able to rest more, and been more emotionally capable during the true labour.

Now, when I’m working as a doula, I try to help people deny the niggly prelabour stuff. If you think of the early symptoms like the start of a period then you may be able dismiss the first signs of labour (the “forget it” stage). Sure, we talk on the phone during this period, but you certainly don’t need to time anything. If you only attend to the active part of labour, where you can no longer deny it, it will feel like your labour is shorter. (Like a client this year who denied things so beautifully throughout the day that she asked me, "Do you really think I'm in labour?" when I arrived at her house. It was only 5 hours later that her first baby was born.)

Now, I watch the momentum of labour, the woman’s movement, her face. Is she flushed? Are her knees bent? Is she rising onto her tiptoes at the peak of a contraction? How much clothing can she stand to wear? What sounds is she making? All these things tell me how her labour is progressing. But I’m not the “keeper of the wisdom.” In prenatal visits, I share all these secrets with clients.

I just love it when I get a phone call from a dad..."Uh, she’s doing that thing you showed us on the chair. The contractions only started half an hour ago, but I think we should just meet you at the hospital." I can hear her low moans in the background. It’s so great to know that he “gets it,” and hasn’t had to rely on timing contractions to determine the fast progress of her labour.

If you truly MUST write down the contractions (for the baby book), do it. It can be a fun way to keep busy during early labour. But it’s only good at showing you exactly when active labour starts. When does that happen? Well, the moment a woman says, “Put that pen down and rub my back!” she has reached the start of active labour. Oh, and another great indicator of the beginning of active labour is to play a game of cards. I was at the hospital with a woman who was being induced. “When will I know that it’s REAL?” she asked. “Well, when you throw your cards at me,” I said. It was only another half hour later that she threw the cards down. “Now, I know what you mean,” she laughed, as she jumped out of the bed. Ahaa! She had entered active labour.

So, here’s a great way to access your instinctive side: Take off your watch, turn all the clocks around... and feel the rhythm of contractions. For example, you can lean on the kitchen counter for a contraction, then pick a walking circuit around the house. You might have to walk three circuits before another contraction comes. After an hour, you may only be able to complete two circuits before the contraction comes again. You will know “in your body” the rhythm of labour, and won’t need to focus on time any more. Once you are able to flow with the labour, this will encourage a trancelike state (ah, endorphin release!), and help you go deeper into labour. But, always remember to keep in touch with me and your midwife or doctor. Oh, and we’ll know that it’s time to go to the hospital when you can’t walk another circuit (I will certainly be with you by that time!)

Every labour is totally different. Some women follow the textbook and have contractions which increase in length, strength and frequency. Other women can have contractions which are fast and furious from the first contraction. On rare occasions, some women find that their contractions are “pokey” all the way through. Labour is not a linear process; it ebbs and flows as the body and your baby requires. I will help you navigate this rhythm. When I talk to you on the phone, I will be thinking about how many times you have to stop talking (i.e. have a contraction) within a 10-minute period. In early labour there might only be one contraction every 10 minutes. Generally, in active labour, 3-4 contractions will occur in each 10 minute period. But the sooner you can let go of time, let go of your “thinking brain,” the sooner you will experience the timeless rhythm of labour. You will be able to cope much better.

So, I encourage you to trust your body’s rhythm, drawing guidance from your chosen caregivers. Talk to your doctor or midwife in advance about phone contact in early labour. Remember, you’ll be talking with me on the phone A LOT in early labour, and I will come whenever you need me. My arrival isn’t based on time, but on your need for extra support. Or your partner’s need for support! Then...I’ll be there.

Helping mothers open the door to life

Journalism students at Langara College produced eight weekly issues of The Voice newspaper. As a final test of endurance the pressure was ramped up and in the ninth week they produced four daily newspapers. Adam Johnson's submission made the top story in "The Best of the Dailies!"


“A 65-year-old midwife held my foot and she didn't move. Then she would look up and she'd smile. And I thought, obviously things are okay.”

“I just said, I need to do this.”

The deep kindness in her eyes grows determined as Jacquie Munro, 45, describes the day she found her calling. She was inspired by her second birth to share this positive experience with others. That was 18 years ago.

“It altered who I was radically,” she says. “I wanted to change people's lives the way they had changed mine.”

She began working as a childbirth educator, but when her students kept having difficult births, she decided to guide the next batch through the process first-hand. Eventually, it became a fulltime job. While she initially called herself labour support, the word Doula came into use in the early 1990s.

Doula is a traditional Greek word referring to an experienced woman who helps other women through childbirth. In its modern connotation, it is someone who counsels the mother before, during, and after childbirth, without actually birthing, or “catching” the child.

It is a job of simple acts, small gestures, and one hell of a lot of work. “It's often just eyes and hands—and just one word,” she says. “I just say, you are safe.”

On her kitchen table, Munro looks over a huge stack of file folders, each representing one of the 602 lives she has helped into the world. “God, I've been doing this a long time,” she says, smiling at the size of the stack.

She says the most important thing she does is provide continuity of care, by being there for the mother during the entire birthing process.

She says this continuity is sorely lacking in the current health care system, where mothers often deal with overworked health care workers.

Munro acts as an intermediary between the mother and the health care system, arranging the trip to the hospital, consulting with doctors and nurses, and maintaining a safe atmosphere for the mother.

“In births where there isn't anyone looking over the mother, a woman's autonomy can be lost completely,” she says. “You become a patient, which is usually very submissive.”

Munro seeks to create an atmosphere and mindset where a mother can get into the “birth trance,” a state of surrender and acceptance that allows the childbirth to proceed naturally. “It's completely analogous to lovemaking,” she says.“You cannot surrender to the process unless you are safe.”

But Munro insists the labour stage is the least of her concerns, pointing to staffing shortages at hospitals and the limited availability of rooms and medication. She is also concerned with the recent trend towards cesarean sections in place of natural childbirth because of the serious health risks associated with this procedure.

However, when necessary she uses all the tools of modern-day childbirth. “Labour pushes you to the very edge of what you think you can do, but it shouldn't be torture.”

After hundreds of births, Munro still finds profound meaning in the experience.

“When I'm in there with people in birth, it's like the door between life and death is wide open,” she says.

Munro presents a happy and vibrant personality, and demonstrates the limitless patience of someone who spends days massaging backs and easing nerves.

But there is a deep, underlying fatigue associated with work that requires such an emotional commitment.

“Last week I did three births in two days. I had four hours sleep in 64 hours,” she says, smiling. “But it's great.”

by Adam Johnson
Langara Journalism Student (Certificate Program)

On Memories

"So much of our early gladness vanishes utterly from our memory: we can never recall the joy with which we laid our heads on our mother's bosom or rode on our father's back in childhood; doubtless that joy is wrought up into our nature, as the sunlight of long-past mornings is wrought up in the soft mellowness of the apricot; but it is gone for ever from our imagination, and we can only believe in the joy of childhood."
George Eliot, Adam Bede

Conscientious parenting begins before our children are born. Writing a pregnancy and birth journal can help to create wonderful memories for our babies. My own children loved it when I read my journals aloud at bedtime.

Sarah would ask, “What did you do before I was born?” She was fascinated to hear about what daddy and I had done in those weeks of waiting in the August heat. She loved hearing that she had tried to forge her own path out of my body. "You wanted to come out facing forward, so you wouldn't miss seeing a thing! But you finally spun around and came out with a splash!"

“Read the part about how I peed all over you!” my four-year-old son would laugh. Then I read to him, “The midwife told me to open my eyes and look down. Someone held my head and helped me to curl around my tummy as you tumbled out onto my leg. You were so heavy and slippery. Then you peed - so hot! - up my body. And we all laughed! And your daddy cried as he called out - It’s a boy! We couldn’t believe it. We were sure we were having another girl. Then we said your name - Alexander.”

These stories are like family rituals, forming a strong core onto which all the other family memories bond.

“You say you want a revolution/Well, you know/We all want to change the world"

“Crisp and non-preachy” is how John Lennon’s Revolution was described on the radio today. After almost 40 years the form of the message is still unmatched. What would John Lennon have said about the social and political climate in 2005?

I think I’m pretty clear on what he might have said about George Bush and Iraq. But what would he have thought about the “Britney Spears School” of birth? Would he have commented on the “Too Posh to Push” scene? Would he have questioned why women seem to be so scared of their bodies?

This evolution (devolution?) in birthing practices seems to be leading us towards the world portrayed in 1984 or The Giver. How do we call for a change, a revolution, in the birthing world, without sounding preachy? How do we stop the loss of “normal birth?”

These questions made me sit down today to check out my 2005 stats. I needed to look at them to see how many “normal births” I’d attended this year. I’m so pleased that, out of the 79% spontaneous vaginal births, 61.4% of my clients had simple no-fuss births, and only 3% had unexpected cesareans. So I think you can say I’m part of a revolution against the “Too Posh to Push” tide, one woman at a time. And don’t think that my clientele is skewed towards young “low-risk” women. The majority (56%) of my clients are over 36 (10% of which are over 40).

What I do isn’t about the stats AT ALL . My aim is to help each woman forge a memory that is positive and empowering. There is no judgement against the women who need cesareans or epidurals, forceps or inductions. Actually some of my clients who have very difficult, intervention-filled labours are the most empowered by their experience. But I try to keep things as simple as possible for everyone, to ensure the smoothest transition to parenthood. My greatest joy comes when I hear, “If I can get through labour, I can achieve anything!”

When I hear that, I know we can start a revolution...

70 births so far in 2005

Spontaneous Vaginal Birth 79% (55)
Assisted Birth 5% (4) (1 vacuum, 3 forceps)
Cesarean birth 16% (11)
13% Booked (7 breech, 2 sets twins) (What's with the 10% breeches?)
3% Emergency (1 fetal distress, 1 transverse arrest at 10cm, both w/previous epidurals)

Simply Straightforward Birth (i.e. No intervention, no meds, excluding nitrous oxide or TENS) 61.4% (43)

Epidurals for Vaginal Births 21.4% (15) Reasons: 4 to stop early involuntary pushing (1 resulted in vacuum), 1 hernia pain, 1 prophylactic for low platelets (w/no further complications), 3 for pain (2 resulted in forceps), 5 with oxytocin induction/augmentation, 1 for forceps (baby to SCN)

Place of Birth
Hospital Births 93% (65) BC Womens (51) (1 diverted from St Pauls), St Pauls (11), Lions Gate (2), Royal Columbian (1) (diverted from BCW)
Home Births 7% (5) (4 planned w/midwives, 1 unplanned w/paramedics!)

Caregivers
57% (40) Family Practictioners
34% (24) Obstetricians
9% (6) Midwife

Client Age
20-29 11%
30-34 33%
35-39 46%
40+ 10%

- Jacquie Munro, Vancouver Doula

“There’s snow! That means it’s winter, so the baby must be coming!”

...to paraphrase an excited older sibling (age 4) this morning...

So cool that her logic worked so well. Mummy and daddy have said for 9 months that the baby will come in the winter. It snows in the winter. Today it is snowing. Therefore, the baby must be coming today.

And the baby came. What a drive through snowy streets to the hospital! What joy to find that my client had already surpassed her last labour’s dilation! What a triumph for her to labour without intervention or medications (other than nitrous oxide gas - which doesn’t count, right?) and birth (with under an hour of pushing) a glorious 9lb 1oz baby girl!

This VBAC (vaginal birth after cesarean) was the talk of the hospital today. Congratulations!

- Jacquie Munro, Vancouver Doula

Mail sampler (to encourage new mums)

Dear Jacquie,

Sam is 10 months old now, and doing really, really well. She is a very mellow, happy baby (and she sleeps through the night which makes life SO MUCH EASIER).

My birth experience has stayed close to me through everything - to be expected, I suppose, but it has become a memory that I draw on when I'm having one of those tough days (i.e. not enough sleep, Sam teething, Sam not eating her peas, all of the above in combo with PMS - I *so* didn't miss my menstrual cycle...). My memories are overwhelmingly positive, and much of that has to do with your calm presence throughout. You set the tone, you guided me to that place where I knew that my body would - and could - do what needed to be done. That strength and confidence has made all the difference, particularly during the early months when everyone around me seemed to think they knew what Sam needed better than I did; whenever I've had doubts, I've gone back to that basic trust in my body, and it has so far given me the best advice.

My trust in my intuition, and in my body's ability to take care of itself and my babe, is at the very core of my mothering. I think that your guidance through the birth helped me find that - and for that I thank you. I hope you're available when we do this again! I'm really looking forward to it. How weird is that? I must be ovulating... ;-)

I hope all is well with you and yours!

Maureen

“In and out like a fiddler’s elbow”

I laughed when I heard this expression on CBC radio this morning. It’s supposed to mean that you’re really busy. Well - that was me this week. It had started out quietly...

And then...

Three births in two days. But the crazy thing is that I didn’t get more than four hours sleep in 64 hours. People said I looked alert and I felt fine the entire time.

I know that if I’d been at only one birth I would have fallen apart. But attending three births, each with their own special atmosphere, flavour, challenge and fun, seems to be what made the difference.

Challenging and fun it was!

It all began with another day of diversion at BC Women’s Hospital. Funny word “diversion.” The dictionary definition is “an activity that diverts, amuses or stimulates.” Hah! Yes, it is certainly stimulating when the hospital is on diversion. In hospital-speak, diversion is when the hospital cannot accommodate a patient. That’s just fine when it’s a general hospital. You just wait. But labouring women can’t just wait. You get sent, or “diverted” to another hospital. On Wednesday, my client was sent to Royal Columbian Hospital. The next patient after her was sent to Ridge Meadows...the next to Victoria. It’s too upsetting to think about those other women.

Luckily, once my client arrived at RCH, she was given the top birthing room. She dubbed this “The Las Vegas Suite” because of the oversized bathtub smack in the middle of the room. Details aside, this was an amazing birth. She showed such strength and power, trusted me when I said “You are safe,” and pushed out a glorious 9lb 11oz baby boy.

When I returned home on Thursday at dinner time, I didn’t go straight to bed. I wanted to enjoy the evening. How silly of me... I was out again by 11pm, heading for a home birth. I was relaxed. I knew there would be no emotional struggle against the system, no worrying if there was room at the inn. We just had to honour the flow of labour.

Well, there was one moment of anxiety when my client worried that the baby might be born before her older child woke up. No need to worry, though - we had tucked her and the new babe into bed, cleaned up the house, and driven away before her daughter ran into the room. What a morning of discovery for the family!

Then, when I’d only been asleep for two hours...

The pager vibrated off my bedside table. A client needed an emergency induction. The self-described “pessimistic” obstetrician held out little hope for a vaginal birth. But, after only 9 hours of active labour, and “optimistic” heroics supplied by the family practice doctors, my client greeted her gift of a lifetime - a wide-eyed son. Not a small feat for a 43 year old single mum who had hardly dared to dream about this day.

I drove home at midnight. The nurses called out to me as I left the building, “Drive slowly!” “Be careful!” “Keep the windows down!” “Sing loudly!”

I thank them all for their care.

Dawn Streetlamps

there is something beautiful
about the sight of three midwives standing outside
at dawn
under the halo of streetlamps
sifting through the night's events

a neighbour leans out of a doorway
Have they had the baby yet?
Yes!
Is it a girl?
We can't tell you!

laughter as they drive away
the tires shushing on wet roads

- Jacquie Munro, Vancouver Doula

"Take no advice...follow your own instincts...use your own reason, to come to your own conclusions" - Virginia Woolf

This week is shaping up to be “postpartum visit week.” Lots of wee boys (and their tired mums) to visit. I’ve also heard from clients whose babies range in age from three to eight months. We’ve discussed everything from sleep deprivation to “what the poo should look like.”

The major issue this week isn’t (thankfully) breast-feeding. Pretty much everyone is doing well and producing abundant quantities of breast milk. One client is even donating her extra milk to the Children’s Hospital Milk Bank, (604) 875-2345, ext. 7607. Another just phoned to say that, with the help of Renee Hefti-Graham (604-733-6359), her little girl finally latched successfully at six weeks and is doing so well! All the other babies are latching well, gaining weight, sleeping (at times) and peaceful (at times).

What seems to be causing anxiety this week is the overwhelming contradiction between a mother’s instincts and outside influences. Books, family, friends and complete strangers are undermining the mothering instinct for so many of my clients.

A client of a one month old was doing “just fine, thank you very much” until her sister gave her a book advocating strict scheduling of feeding and sleeping. After trying the suggestions for a few days, her baby was up every hour at night and no one was getting any rest. I asked her what her instincts told her to do...and she said, “To feed him when he wants, or when my breasts need relief, to pick him up when I feel like it, or when he cries, to carry him about, talk to him - whatever just feels right. But my family keep telling me that I’ll spoil him, and I find I’m second-guessing myself. It’s making me crazy!” Sounds sadly familiar...

Another client whose baby is three weeks old remembers being told to feed her baby every three hours. She found herself resisting the urge to feed her baby when he started crying every hour. Classic “three week” growth spurt symptoms! The baby was demanding more time at the breast in order to increase the mum’s milk supply. The only reason she resisted the urge was because of a comment made by the visiting health nurse weeks ago. Not trusting herself and her baby was leading to anxiety and conflict.

“But I just fed him!” is the common cry. Well, think of him like a 16 year old boy in the middle of the biggest growth spurt of his life. You’ve made dinner (which he wolfed down), and then, only an hour later, he’s hungry again! So he orders in a pizza. Then he miraculously grows 6 inches in a few months. Ahaa!

Newborn babies are just like that 16 year old boy. Their feeding patterns will vary from hour to hour and day to day. Sometimes they’ll pig out from 6-10pm (cluster feeding), and then the next afternoon they’ll sleep 3 hours. Problems only seem to arise once we start to throw our Type A controlling brain into the mix and start to analyze things. “Hmmm...let’s see, well, he slept three hours after we were out all morning, so I should try that again.” No luck next time... Just like living in the moment works well in labour, so it works in the postpartum period. The newborn baby will be a changeable being every day. Trying to discern patterns in his behaviour during the newborn period is a futile attempt at control. Oh, and you can’t spoil him at this point.

When I had a newborn, I always reminded myself “to think like a cave woman.” No clocks, no books, no scheduling, no “shoulds.” I turned the clocks around so that I wouldn’t be able to remember how many times I was up in the night. I allowed the passing of the night to become fluid, a zen time of quiet movements and silent feeds. I threw away the hospital feeding / voiding chart and tried to pretend that this was my fifth child, and that I had faith in my body and my baby’s ability to work well. I threw away the bra pin - the one that was supposed to remind me which breast was next. I would gently “weigh” a breast to determine where my baby needed to latch (have him take the heaviest!). I would read novels and poetry and children’s books aloud during each feed. And if I continued to hold the baby in my arms between feeds, just for a little more quiet, and a good read for myself, then I wouldn’t feel guilty. And if I needed to turn on the fan or the vacuum cleaner, or dance around with my baby in my arms just to soothe him (every night), I didn’t think we had a problem. I just accepted it as necessary in that moment. And if I had to head out for a drive to UBC and back (all the while listening to CBC Ideas) just to settle an especially cranky little one...and then woke the baby while tripping up the stairs...I’d just laugh and ask my husband to do the rounds again.

Sure, there are mornings when you wake up and you feel less rested than when you went to bed. There are days when you sit all day at the computer, reading the UBC calendar, just to see what you could have been doing if you hadn’t had a baby this year. And sure, there are nights when you crumple into a sobbing heap because that sweet little baby STILL hasn’t fallen asleep. And there really are nights when you wonder what you were thinking having a baby! That’s when you need to gather all the amazing people around you who REALLY support you, who won’t undermine your instincts, who will tell it like it truly is, and still be there to help - without judgement or advice.

What you need is a group of like-minded souls who honour motherhood. So, give me a call first, then start attending mum’s groups, even if you think your baby is the most colicky baby possible. We will understand. I will remind you of the strength you showed in labour, how hilariously out of control this all is, and that you are at the beginning of an incredible learning curve, so you need to be gentle on yourself. I will remind you that your baby is like no other. Your little family is like no other. You need to find your OWN way through this parenting maze without judgement or expectation - and yes, it will be a roller-coaster for a while. You will arm yourself with friendship, laughter, music, dance, walks and sleep whenever you can find it. Then you will gradually slough off your old Type A controlled existence (ah, such a challenge) with as much grace as you can muster. Together, we will help you to build up your confidence, and build strong boundaries about your new family, so that inconsiderate remarks and unwanted advice don’t undermine your fragile world.

And at six weeks, or three months, or at eighteen months...you will be at a point where you can say. “Wow, that was a ride!” But, supported by all those around you, you will have made it to a place where you might even think about doing it all over again...Then, Hey - call me!

Intuition, Trust and Red Flags

It’s funny how, over the years, I’ve only been given the births that I can handle. Each birth prepares me for the challenges of the next. What amazing gifts these women give to each other.

When I began my life as a doula, I was still breastfeeding my one-year-old son. I knew that I could only manage six hours away from him. For me - I couldn’t stand the breastmilk backlog! For him - hey, he needed me. For the first year, the births were amazing. I was never needed for more than six hours. I was only faced with long births once my son was able to go longer between feeds. Though I do remember pumping midway through long births for a few years...

Each birth has taught me an amazing lesson. For example - the very first birth I attended as a solo doula was a 4 hour vaginal breech birth. Being a new doula, I was nervous about the possible challenges with this birth - I’d read my medical text books! But my client was unperturbed - she had been born breech herself. So, when she went into labour and her husband was nowhere to be found, she called to say we should meet at the hospital, then called her doctor and asked him to pick her up on the way. Then she actually made the doctor take her through McDonald’s drive-thru so she could pick up a Big Mac! “Why not!” he said. Well, that baby came so easily and swiftly. “It wasn’t as bad as a rowing workout!” said my client after that baby was born. Wow! That was my first lesson in trusting the client.

At that point, I realized that our internal knowledge is strong. My client’s birth had gone smoothly because she wasn’t concerned for her or her baby’s safety. She wasn’t being irresponsible or foolhardy either. She just totally trusted her body to work well. I believe she would have had a sense if something was wrong - and would have acted on it. That’s just the way things work. Problems only arise if the woman’s intuitive sense is blocked, or if she is forced to second-guess herself. That results in fear, which further complicates matters. But those are things that we discover during our prenatal visits.

You might argue that we can never anticipate when a medical emergency is going to happen - that some emergencies come out of the blue. Well, yes, sometimes the course of a labour can change in a moment. But it is never without warning signs. The problem is, women’s intuition is not being honoured, and caregivers aren’t continuously with the woman, and miss the warning signs. As an experienced doula, sometimes I’m the only person who is consistently there, knowledgeable enough and detached enough to see these warning signs.

I was with a woman in labour at St Pauls. On paper, things appeared to be going well. She was at 5cm, unmedicated, had intact membranes, and was rocking back and forth on her hands and knees. But she was worried. She kept having images of the baby pushing his head out of the pelvis. The staff were busy with the shift change, laughing and joking. The new doctor on shift, who I know well, asked if I had any concerns. I went into the hall with her, and told her about the woman’s image of the baby. I also told her that I had a very strong intuitive sense that something was wrong. I “felt” a bad odour coming from the woman. The smell was so subtle, but ominous. The doctor went back into the room and couldn’t smell anything odd. I said I just knew that something was different, that I couldn’t shake the bad feeling that I had. The doctor stayed in the room for the next hour, monitoring the woman’s contraction pattern by using her hands, listening carefully to the baby’s heartrate. After an hour of seeing the baby’s heartrate climb, she asked the labouring woman what she thought - intuitively. The woman looked at her doctor - “Intuitively? I think I need a cesarean. But that’s crazy, isn’t it?”

“No, we’ll do it,” said the doctor, “I trust women’s intuition.” And, yes, you guessed it - the smell in the OR was terrible. My client had a massive uterine infection. I was right, I had smelled the change in her body. And the woman’s sense that the baby didn’t want to come vaginally, that he was pushing away from something, was correct. The mum and baby did very well after the surgery, but it had been a close call.

Babies are great with red flags. They madly wave those red flags. Our problem is that we often don’t recognize what the baby is doing. When we trust our instincts, and listen carefully to what a labouring woman is saying, we can learn so much more than is available to us through vaginal examinations or heartrate monitoring.

Think about how often the baby’s heartrate must dip during pregnancy. If mum lies in such a way that the baby’s umbilical cord is compressed, the baby kicks up a storm, mum rolls over, all is well. If mum is sitting in a deep sofa, which the baby finds uncomfortable, she’s forced to stand up and stretch. During pregnancy, we hardly realize all the things that we do in a day in response to the baby’s needs. We dance with our baby throughout pregnancy, an ongoing interplay. We keep our baby safe.

One woman in labour kept saying that she had an image of a rock climber, with the ropes wrapped around his chest, one hand on the taut rope on the rock wall. Her husband laughed and said, “You’re remembering our first date!” “No, it’s an insistent current image,” she said. She reached full dilation and started to push. Every time she pushed, the baby’s heartrate dipped (sometimes that’s an encouraging sign, sometimes it’s not...) Well, after three hours, the baby hadn’t descended at all. In fact, the baby had popped out of the pelvis. The obstetrician said his classic line. “That baby’s not even in Vancouver! He’s so high, he’s in New Westminster!” My client talked about her image of the rock climber again, and agreed to a cesarean birth.

Well, guess where the umbilical cord was? Wrapped around his chest like a rock climber. And he had his right hand clutched onto the taut cord, just like his dad had done on the first date. The couple laughed and laughed, feeling great about their decision. “I’ll trust you next time,” said the dad.

I’m so thankful for the lessons I have been taught by my clients and their babies. I have so many examples of how trusting a woman’s inner knowledge, trusting the baby’s red flags, and being continuously present, can positively affect the outcome of a labour. Women are empowered when their inner knowledge is honoured. It makes them more confident and results in joyful parenting.

But I’ll dole out the stories slowly. It’s time to call a new mum and have her teach me some more...

- Jacquie Munro, Vancouver Doula

An Education in Care

If you want to get the inside scoop on birthing practices in BC, stand outside a kindergarten classroom just before the end of the school day. You’ll find a group of young mothers, with babes in arms, waiting to pick up their 5 year olds. They’ve been through the system - probably a few times - and are only too happy to share their hard won stories. Ask about their first birth experience, and you may hear stories of disillusionment, loss of dignity, overcrowding, or lack of continuity. They’ll tell you they wish they’d been better informed, and had known enough to find great caregivers.

Then there will probably be one woman in the group who shares her second birth experience, and shyly admits to feeling joy. “What a difference my second birth was!” she’ll say. “It was like night and day!” You might hear her talk about empowerment and laughter. What was the difference from her first birth, you ask? “Oh, I changed caregivers...and I hired a doula.”

Sadly, the majority of us stumble onto our maternity caregiver. Perhaps our family doctor doesn’t provide obstetrical care any more and refers us to a local obstetrician. Perhaps a friend gives us the name of the doctor who performed her D&C last year. Since there is often an element of surprise involved in the discovery of our first pregnancy, very few of us have the luxury of time to research the variety of available care in our area.

We are also victims of American media, watching their TV shows and reading their books, and mistakenly believe that an obstetrician will provide us with the best care possible. The system in BC is quite different from that in the U.S. The obstetrician doesn’t necessarily provide the best care for our particular needs (this is quite separate from being a good caregiver) - and most assuredly does not provide the greatest continuity of care. Many of the obstetricians that I work with will be the first to admit that their skills are best utilized by those who truly need them, those at high risk, and not by the average normal healthy pregnant woman. “You don’t want to see me walk back into this room,” said one obstetrician to my client the other day, after consulting with the woman’s family doctor. “I’m the surgeon.” Happily, this woman’s labour ended smoothly, without further consultation from this wonderful obstetrician.

Here’s the explanation provided by the BC Women’s Family practice Maternity Service: “In BC, family physicians, registered midwives, and obstetricians are all licensed to provide maternity care. Women can see any of these three caregivers: however, obstetricians are specialists with extra training in surgical skills and management of complicated pregnancies. They typically see women with complex pregnancy issues. Most women see either a midwife or a family physician. While both midwives and family doctors provide excellent care for the expectant mother, choose the caregiver that makes you feel most comfortable.”

In terms of continuity of care, your own family physician, if skilled in the area of obstetrics, might perhaps be your choice. This person would have prior knowledge of you and your family, be able to care for you during your pregnancy, both obstetrically and medically, and provide postpartum, baby, and family care afterwards. However, this “small-town” approach is rapidly disappearing.

Many family doctors these days have withdrawn obstetrical services due to time constraints, increasing insurance costs, or lack of experience in this area. Increasingly, family doctors refer their pregnant patients to another caregiver. It is worth doing as much research as possible before accepting a referral for maternity care. Know your options, then make an informed choice about your maternity caregiver. This decision will determine the standard of care for your birth experience, perhaps one of the most important experiences in your life. So take your time.

Regulated in BC since 1998, midwives are experts in healthy pregnancy, normal birth, and well babies, and are respected members of the BC medical system. Midwives attend births both at home and at hospital, following strict protocols governing safety. Their services are covered under the BC Medical Services Plan. The Midwives Association of BC website includes listings of midwives in your area. The College of Midwives of BC website provides more in-depth information on the model of care, standards, and education.

For those women whose family physicians no longer provide obstetric services, BC Women’s Hospital, Royal Columbian Hospital, and Lions Gate Hospital all have family practice maternity services. The doctors at these clinics are general practitioners who specialize in obstetrics. These doctors work in rotation to provide prenatal and birth care. At St. Paul’s hospital, there are some more informal groups of family physicians who will accept referrals for care during a woman’s pregnancy.

If pregnancy complications arise, both the midwife and family physician consult with other medical personnel, but remain involved in your care. If either the midwife or family physician requires an obstetrician’s consultation, then they are often able to select the caregiver most compatible with your personality, and most competent to deal with your particular concern on that day. This part of their service is particularly critical these days, with hospitals being stretched to their limits.

So, what are the odds of having your own midwife or doctor attend your birth? Midwives generally work in teams, with perhaps two or three midwives working in rotation. At a home birth, there are always two midwives in attendance. Continuity of care is of great importance. Very few doctors take all their own calls. The majority of family practitioners work in call groups of up to six doctors, working shifts of 24 hours. Some attend their patients’ births during the week, and rotate call on weekends. Many of the groups have “Meet the Doctor” nights, where you can visit with all the doctors in the call group, and listen to them talk about their philosophy.

If your pregnancy is complicated, or becomes complex, you may be working with an obstetrician through your labour. Remember that all obstetricians work in large call groups (of 8-20+ OBs), and are on call for 12-48 hours at a time. During that time, each obstetrician is responsible for his or her own patients, plus the patients of the other physicians in the call group. Because of the surgical work load, and for teaching purposes, an obstetrician relies on an obstetric resident to provide care for the woman in labour. Either the resident (junior and/or senior) or the obstetrician (or all) will be present for all procedures, and at the birth. At these more complex births, the nurse’s role and the doula’s role are critical. Since the physician who you have seen in your prenatal visits is unlikely to be present for your birth (or busy in the OR), the nurse and doula are left to provide continuity of care, and to work closely together to complete a multitude of tasks. Highly technical births need that extra bit of human touch, and we must all work diligently to make you feel honoured and empowered during this more challenging experience.

In all cases, whether you work with a midwife, a family physician, or an obstetrician, I will work with your caregivers to provide continuity of care. I will act as “translator,” working to facilitate open communication between you and the medical staff. I will provide physical and emotional support for you and your family, and make sure that you are provided with all the information so that you can always make informed decisions. I do my best to help you feel empowered by the process, to feel safe.

And I hope that, when you are that mum standing outside the kindergarten classroom, you will share your birth story and be able to smile and say, “I’m so glad I had such great care...and my birth was great - it was challenging, but it was amazing!”

- Jacquie Munro - Vancouver Doula, Slow Birth, Slow Planet

Full in the hand / Heavy with ripeness

For Maddox

To feel a baby's head for the first time
full in the hand
heavy with ripeness
is a sacred act

To feel the vernix slick
the fontanelles molded
the marble-hardness
the heat of it all

The sensation remains in my hands still
more than twelve hours later

Necessity made me reach down
to slow this baby's arrival
to make him come gently

I called for her to touch her baby next
and she did
but she should have been
the first
to feel her baby touch the air

a sacred first

I will guard this feeling

the baby's wisdom remaining
on my fingertips


“Full in the hand/heavy with ripeness” are two lines from a Marge Piercy poem about love-making. I have always loved these lines, and thought that they could also refer to a newborn at birth. But I had never fully experienced that connection until I held Maddox’s head in my hands. Until then... I was never moved enough to spill the remaining lines of my own onto the page. - Jacquie Munro, Vancouver Doula

Labour-Aid

1/3 cup fresh lemon juice
1/3 cup liquid honey
1/4 teaspoon salt
2 crushed calcium/magnesium tablets
plus enough water to make up 1 litre

Blend together and pour into ice cube trays or drink "straight" during labour.

The Doula Solution

Here's an article from the Winter 2001 issue of
Western Living Magazine about my doula service:

When the contractions begin and even Dad starts screaming for drugs, a little backup is a good thing.

Six hours into labour, Dad's feeling like a third wheel at the bedside. He wants to help, but he's not sure how.

"What does it feel like?" he asks his wife.

"Sour!" she hisses.

Sour? He has no idea what that means.

"It could be lactic acid she's tasting," explains the ultra-calm woman who has been massaging his wife's feet for the past three hours. "The uterus is a muscle and it's working hard. This is perfectly normal." It occurs to this man that a stranger is sharing the couple's most intimate moment. And damn, but he's glad she is.

She's a doula. "I'm labour support," says the veteran Vancouver doula Jacquie Munro, 'although when I tell people that, they think I work in union administration."

"Certified doula" is a job title that would scarcely have been imaginable earlier in history, or in a less driven culture. (Extended family or a community elder would have helped a mother through her delivery.) But somehow it's fitting that, in the age of the private trainer, more couples are embracing the idea of a personal birthing aide.

A doula is not a midwife, she isn't licensed to intervene medically; she has no particular agenda with respect to drugs or childbirth methodology. You might think of her job as simply full-service care from the ribs up (foot massages notwithstanding). Whatever needs doing - from decoding physician jargon to wrangling agitated relatives or zipping home to feed the cat - the doula just handles it. "I'm kind of the little guardian angel who just makes sure that everything is running smoothly," says Munro, a former graduate student of developmental psychology who also taught the first course at Douglas College's doula program. "I'm also the walking encyclopedia. I don't tell people what to do, but I do give them the tools to help them make informed decisions."

You're not alone if you've never heard of doulas. The term was only coined in the early 90's and derives from a Greek word that means an experienced woman caregiver of another woman. "I think they found out, actually, that it almost means slave," says Munro. "Historically, that's who was looking after other women in labour."

Munro noticed a spike in demand for doulas around five years ago as word spread, via the prenatal-class telegraph, about this option that radically reduced stress and the chance of knifework in the delivery room. There are 475 Canadians registered with the 2,500-member strong Doulas of North America Association (DONA). but since registration isn't obligatory, the actual number of doulas working in cities across Canada is unknown.

Because the doula business is, well, in its infancy, a certain amount of confusion surrounds it. For one thing, the term is understood to mean different things in different places. In New York, where hiring a doula has become de rigueur among turbo-professionals, the doula isn't present at the birth; she's sold more as a housekeeper. "Some doulas literally move in the day you get back from the hospital," explains Vancouverite Sara Dubois Phillips.

Dubois Phillips's husband hired a doula for her as a surprise gift when she was pregnant in Manhattan - though the arrangement proved a bit claustrophobic. Still, says Dubois Phillips, there were initial benefits: "She could tell me how other women had handled what I was going through, because at that time none of my friends had kids. That's why doulas are such a phenomenon in a place like New York, where everyone is a transplant."

The doula is a support system for both partners, but dads seem to benefit most - especially in late-stage labour. When he needs sleep, she spells him off on the back massage. If he starts to flip out, she quietly, constantly, feeds into his ear what guys crave most: data.

"My job is to make him look so good - without being condescending," says Munro. "I try to ensure that he's directly in her line of vision, so that whenever she opens her eyes, he's there. I'm putting the drinks in his hand. I'm handing him the cold cloth. And all she knows is, He's incredible." - Bruce Grierson

CBC Radio is back!

What’s the connection to this blog? To birthing and mothering? Well, CBC Radio has been the backdrop to my life. It formed the beautiful predictable ritualistic structure for my mothering at home.

CBC Radio 1 has brought form to my life, acting as “comfort food for the mind” when I was a child, bringing sanity to my early years as a new mother, and helping me to parent young adults consciously and conscientiously. So, rather than encouraging new parents to seek out parenting information from "The Baby Whisperer" or other books that address structure and scheduling, I just encourage new mums to stave off loneliness, provide intellectual stimulation AND provide structure by simply turning on the radio.

“As it Happens” meant that it was dinner time when I was a child. “Morningside” with Peter Gzowski brought structure to my mornings when my own children were small. The sound of the beeps which signal 10am meant that I should put the kettle on for a relaxing cup of tea. The noon news reminded me to put aside the playdough and make lunch for us all. The Wednesday morning political panel of Stephen Lewis, Eric Kierans and Dalton Camp was always on the radio in the car as I drove to my midwife appointment during my second pregnancy. Once my children became readers, I would wait, pen in hand, to listen to Michele Landsberg's (incidentally, Stephen Lewis' wife) book recommendations. And in more recent years, some of my clients at home or hospital have turned on CBC Radio 1 to bring some predictable structure to their labour. One woman deep in labour told all the staff to be quiet at noon on a Sunday, just so that she could listen to Stuart McLean tell the Christmas Turkey story on “The Vinyl Cafe,” in between contractions.

Research has shown that one of the best predictors of superior brain growth and development in children is the amount that a parent talks to a baby during the first year. I didn’t read, sing, and chatter to my children to “make” them into something, but to honour them as the complete little people that they were. So, I’d be working in the kitchen, listening to a radio documentary, and asking my three month old daughter what her opinion was. In the early 1980’s I remember talking to her about a newly discovered disease called AIDS and whether the Russians invasion into Afghanistan would precipitate a global war. I remember feeling so strongly that I was helping my children to grow up as critical thinkers - even at such a young age. And they would look at me with such knowing looks, like all of this wasn’t news to them...

I also remember cuddling up in afternoons, listening to the presentation of the Classical Kids Series of radio plays, like Beethoven Lives Upstairs and Mozart’s Magic Fantasy. I knew I was encouraging my children’s imaginations. In a world increasingly full of speeding images on TV, and the manic fever pitch of video games, I could provide my children with the gift of visual images that can never be duplicated. I knew that each child curled around me was seeing a totally different scene. Perhaps that led to their love of theatre, personal expression, and intellectual bravery.

So, it was with great anticipation that I turned on the radio early this week, waiting for live radio once again. I was looking forward to a new season of “As it Happens” and “Sounds Like Canada”. I was looking forward to listening to the CBC overnight service (a doula’s life involves a lot of driving at 2am). And what was the first thing I heard when I turned on CBC Radio 1 for the first time in months? An advertisement for Stephen Lewis’ October 18th "Race Against Time" Massey lecture at the Chan Centre. I must go listen to him - and take my family.

Things haven’t changed a bit.

from "Fontanelles" by Anne Michaels

We bathe our daughter,
a prayer for every part,
as if we were washing her
with song.
Fingers frail as blades of grass.
Her thousands of eggs,
already inside her.

1999

Effects of the full moon, waning sun, or NHL strike?

It’s been a wild month at hospitals in Canada. At BC Women’s Hospital alone, there were 1000 expected births, with 500 being the norm. You could attribute the increase to the effects of the moon or the sun, or you could put it down to the NHL strike. Who knows! But on Wednesday of this week, all hospitals west of Saskatoon were on diversion - that means NO BEDS ANYWHERE!

There I was, early Wednesday evening, at a client’s house. She was getting deep into her labour, so I had called her doctor just to give her a “heads-up.” She told me something I didn't want to hear.

"Did you hear what’s going on at the hospital today?
They’re air-lifting women to Saskatoon! "

Yikes! I needed a game plan. We were facing minimal staffing at the hospital, no labour beds, and no postpartum beds. The most we could hope for was a bed to birth in if we arrived at full dilation. No epidural, no augmentation, no “on-demand” cesarean. Luckily, my client had been hoping for a natural labour. Heck - there was no other option today.

I silently called for wisdom and calm...

It’s interesting what the mind and body can do when faced with clearly defined boundaries. Quietly, I told my client what needed to happen. She needed to be relaxed and open, and to fully surrender to the rhythm of the labour for it to proceed swiftly and easily. We envisioned a smooth, graceful birth. Lying on her side, with my hand circling her lower back to induce a trance, my client became totally focused. She listened to her body and her baby, moving to the shower then the bath, then to standing. She swayed and rocked and stayed in the moment. Her labour progressed so quickly that it was less than two hours before I knew that this baby was coming soon.

I called the doctor once again.

"The dust is settling. We may have a room. I’m working on it."

It was a beautiful night. We drove through the busy streets to the hospital. As we walked into the hospital I saw another doula who said, incredulously...

"You got a room?!"

We got a room. The only room.

She pushed standing, then kneeling. That baby boy came so beautifully. So many joyful tears. Afterwards, I called my daughter.

"She had the birth I would wish for you."

Funny that when there are no options available, you must make do - and you do very well.

And we did very well again on Friday - another client, same scenario at the hospital - no beds, no meds - and another beautiful boy was born simply and gracefully. Wow - I love how women are able to rise to the occasion.

- Jacquie Munro, Vancouver Doula

“Wow! If you had forceps last time, the next one will just FALL OUT!” (or, crazy predictions and expectations about second births)

I’ve attended so many second births recently, and I have 8 previous clients pregnant at the moment. So, I wanted to convey some of the joy and excitement of working with these second-time clients. I also wanted to talk about predictions and expectations surrounding second births.

So, today, for inspiration, I called a very special client whose little one is now about 18 months old. She picked up the phone and we both started grinning from ear to ear. “I’ve been thinking about you all this week!” she laughed. That’s the joy borne out of spending such an intense and sacred time together during her labour in 2004.

I love what I can do for a repeat client heading into the birth of her second child. If she has any lingering worries about the first birth, we can work on it together - because I was there! If it was a smooth and easy first birth, she may be worried about tempting fate: “It couldn’t possibly be THAT good TWICE!” We get to spend the whole nine months (and more) talking about what to expect. I get to remind her that she’s already a great mum, share stories about our amazing children (who cares that there’s a 20-year gap between our babies), have tea, chat on the phone, and plan for all eventualities. The doula role can expand from its intense focus on the “birth-day” to a broad look at “the big picture.” We can talk about mothering, families, and careers, while making it all relevant to the second birth.

Here are a few of the questions that usually come up during these chats:

“Ah, but how can I love a second child like I do my first?” This whispered question, like a deep secret, is always asked. The love for the firstborn is so profound that it can be scary entertaining the thought of loving another. But, just like the Grinch’s heart was able to expand, our hearts just miraculously DOUBLE in size when that second baby appears. Voila! It just works!

“And how will my firstborn be able to cope with the birth of a sibling?” Especially if there have been more than 3 years between children, the firstborn remembers how good life was before the new baby arrived. “You’re ALWAYS feeding the baby,” said my brother, as he walked past my mum in a huff. My own daughter got creative with a black indelible ink felt pen on the walls of our townhouse - up the stairs, around the corner - then signed it “saraH.” “No, it wasn’t me, mum. It was the other Sara down the street.” “Ah, but Sarah, her name doesn’t have an “H” at the end. Now, you obviously need huge swaths of paper to express yourself these days, don’t you?” And so you adapt, you cope, and the firstborn adjusts, too.

Remember, the firstborn is viewing all of this with the eyes of a small child, NOT the eyes of an adult. After a month, my daughter, then 3 1/2, said, “I did like it better before HE came.” I held onto that comment for years, worrying whether she still resented her little brother. Recently, I asked her about that comment. “Oh, mum, I was 3! That was a comment made in the moment. I would have loved him utterly the next day!” Hmmm.... Right.

“I’m confused. What’s with all these contractions?” This birth will follow a totally different rhythm from the first, and that may play with your mind, and your emotions. But remember, the body doesn’t know you have a brain that is constantly trying to figure out WHEN this labour is going to start. With a second baby, your body may be happily trying to get most of the work of labour done IN ADVANCE of the big day. Cool, eh? Your body can give you mild irregular contractions, or quite a bit of pelvic pressure, over the last few weeks. Your cervix may be quietly thinning, softening or dilating in advance. So, thank your body, let go of trying to figure out WHEN it will shift into active labour, and trust that the signs will be VERY CLEAR. Remember, you can page me whenever you like and we’ll figure it out together!

“I’m 4 cm. already. I’m sure the baby will come today.” During the last few weeks, you may be told “Your baby is really LOW,” “Your baby is really BIG,” or that “You’re 2, 3, 4, or 5 centimetres dilated ALREADY.” Please remember that these aren’t necessarily predictors of an imminent or speedy labour. They just mean that your body works beautifully. Who knows how long you’ve been 4 cm. dilated? You may have been this dilated for weeks. So, please think twice about your decision to have a vaginal assessment prior to labour with a second pregnancy. Think about what you will do with the information once you have it, and if it might negatively affect you emotionally. Then make your choice.

“So, are there any rules for a second birth?” Sure, everyone says that this birth will be about half the length of your first. But, I seem to spend about the same amount of time with both first AND second-timers. What’s that all about? The difference is in what we’re doing during those hours. There’s a lot more tea-making, chatting, walking, and playing with children during the second labour. There’s a lot of waiting for the labour to move from “easy-going early stuff” to the “wild and crazy finish.” Infinite patience and trust in the body are required during this birth. Because, when you least expect it, this labour will finally shift gears, and the baby will arrive with a splash.

There aren’t any rules for a second birth, but here are some helpful notes:

• You may be piddling around in prelabour for days (Don’t worry, it’s all going to help in the long-run)
• You can shift from prelabour to labour in a heartbeat (Watch for this shift in gears)
• Once in true labour, it will probably be MUCH shorter than last time
• Dilation is not a reliable indicator of when the baby will be born (You can go from 2-10 cm. in 15 minutes, or sit for weeks at 5 cm.)
• If you say “The baby’s coming!” it’s coming within MINUTES, not HOURS
• Pushing out a second baby is all about BREATHING it out, not “PUSHING”
• Trust your body...it will surprise you!

- Jacquie Munro, Vancouver Doula

We're Home!

I've only been home from Scotland for less than 48 hours...and two new babies have already arrived. They were waiting for me to come home! One bonnie boy made a dramatic entrance...one leg born in Ladner, and the rest at BC Women's hospital. Spontaneous vaginal footling breech - less than 2 hours from start to finish, and no warning of the breech! What a night! Then a grand boy arrived at lunch-time today - almost 9 pounds of him. I think I can now change from Greenwich Mean Time to Pacific Time.

The trip to Scotland was the best yet! My son's band won the Juvenile World Pipe Band Championship title, Best Drum Corps, and Best Bass. Our Alex, as lead drummer, went up before 40,000 people to accept the trophy for best drum corps. What an amazing day!

And the views from the Dumyat...the sheep...the castles...the ferns and heather...
...they will be missed.

- Jacquie Munro, Vancouver Doula

Spring 2009 - "Mommy, What did you do in the industrial revolution?"

Mommy, what did you do in the industrial revolution? Meditations on the rising cesarean rate.

Plante, L.A. Mommy, What Did You Do in the Industrial Revolution? Meditations on the Rising Cesarean Rate. The International Journal of Feminist Approaches to Bioethics. Spring 2009;2(1):140-147.


Lauren A. Plante, MD, MPH, FACOG
Department of Obstetrics & Gynecology
Thomas Jefferson University
Philadelphia PA
Email: Lauren@LaurenPlante.net

The cesarean rate in the US has been rising for decades, and in 2006 hit an all-time high of 31% (Hamilton, 2007.) This record is likely to stand for only a brief time, that is, until figures are released for 2007. Can it really be that one-third of women are unable to birth without high-level technological support? And is there an endpoint in sight? “In the next decade or so the industrial revolution in obstetrics could make Cesarean delivery consistently safer than the birth process that evolution gave us.” (Gawande, 2006, 8) Against such an argument, who could hope to stand?

In a recent essay on the subject of childbirth, surgeon and author Atul Gawande muses on the Apgar score, obstetrical eponyms, and the rising cesarean rate. (Gawande, 2006) Although he lauds the success—often unheralded-- of obstetrics in saving mothers’ and infants’ lives, I hear within the paean a threnody for the vanishing art. Skilled obstetricians like those legends of the past, whose names lived on in the maneuvers they devised to usher babies into the world, are vanishing from current practice: goodbye, Lovset; hit the road, Rubin; Mauriceau, it’s been swell, but we’re through.

Gawande makes a case for the standardization of obstetrics. “You seek reliability. You begin to wonder whether forty-two thousand obstetricians…could really master all these techniques…obstetricians decided that they needed a simpler, more predictable way to intervene when a laboring mother ran into trouble. They found it in the Cesarean section.” (7) He suggests that techniques for effecting vaginal delivery—maneuvers to reduce a shoulder dystocia, deliver a breech baby, assist delivery with forceps—are so subject to variations in skill that they cannot be standardized for reliably good outcomes, while the cesarean operation is commonplace and consistent. It is, if you will, the least common denominator: every obstetrician knows how to perform one. While this is a fascinating perspective on the changing of obstetrical practice, for those of us who actually work on a busy obstetrical unit industrialized childbirth conjures up images of the factory floor.

The drive toward fewer delivery options appears at first glance to be supported by upper-middle-class women, who have the least number of social and economic obstacles to autonomy. In fact, cynical staff at hospitals delivering large numbers of well-insured upper-middle- class women often refer to their institutions as baby factories: these are the places in which cesarean rates are highest. It is, after all, a paradox: women with higher incomes, higher levels of education, and commercial insurance have higher rates of cesarean delivery. If cesarean is a response to any perceived risk, why would women at statistically lower risk of a poor outcome have higher cesarean delivery rates? New Jersey has the highest cesarean rate among states, (Denk 2006) but no lower levels of maternal or perinatal mortality. (MacDorman 2007, CDC 1999) What it does have, however, is the highest median household income. (Census Bureau 2007)

Does this paradox reflect a differential understanding of risk? I have seen, over years of practice in maternal-fetal medicine, an odd and somewhat unsettling pride among women who announce that they have a “high-risk pregnancy.” Although the inherent literal meaning of the term high-risk pregnancy is one that entails a greater risk of a poor outcome (for mother or baby,) the subtext seems to be that high risk equals high value. In some cases it is difficult to persuade a low-risk woman to continue her care with a general OBGYN practice instead. “But I’m high-risk,” she says. Does she really mean, “I’m high-status,” or “My baby is high-value,” specifically, more precious than someone else’s? Is it a statement of importance? Does it mean that she is special? Or is it a Disneyfication of a primal human endeavor, longing for the synthetic and dramatized experience in preference to the authentic? These questions are raised, but cannot possibly be answered, in this commentary.

Women who want to be high-risk (read: special) in their designation are nonetheless hugely risk-averse when it comes to the real thing. Obstetricians have tapped into that fear in daily practice. Vaginal birth after cesarean (VBAC), for example, is associated with a very low although measurable risk of uterine rupture. Presented with the figures and asked to sign a consent for VBAC which spells out that risk, most women now decline: the VBAC rate in 2005 was under 8%. (Martin, 2006) Whether this is driven by reluctance of doctors to offer or women to undergo VBAC is impossible to ascertain, but it is clear that fear is contagious. And the indications for the initial cesarean—without which the question of VBAC would never be raised—have broadened considerably: breeches, twins, large babies, small babies, slow labor, even no labor. We now see the phenomenon of perfectly healthy, low-risk pregnant women requesting cesarean delivery upfront, in an attempt to eliminate all potential labor-associated risk for the infant. Even in the absence of any medical or obstetric indication for abdominal delivery, many women now seem eager to go under the knife. Somehow a perspective is emerging that cesarean is the best bet for delivery.

National cesarean rates do correlate—inversely—with both neonatal mortality and maternal mortality rates at the extreme low end of the spectrum. For developing or low-income countries, where access to safe maternity care is an issue, a rise in national CS rates from 0% to 8-10% is accompanied by a drop in stillbirths, neonatal deaths, and maternal deaths. (Goldenberg 2007, McClure 2007.) But across the developed world, or across medium- and high-income countries, there is no additional benefit of further increase in cesarean rate (Althabe 2006.): Slovenia, with a 12% cesarean rate, has the same maternal mortality ratio as the US. Nordic maternal mortality ratios are only a fraction of the American, at a 50% lower cesarean rate. Neonatal mortality does not change in high-income countries across a range of CS rates from 10-40%. (Althabe) Infant mortality rates as low as 4 per 1000 are achieved at CS rates of 15% in a number of countries, contrasting favorably with the US infant mortality rate of 7 per 1000: the American system results in infant mortality nearly twice as high achieved at the cost of twice as many cesareans. It is hard to make the argument on a population basis that abdominal delivery is safer for mothers or babies, at least after a minimal necessary rate is achieved.

Nonetheless, seduced by the promise of pain-free, risk-free childbirth, women and their doctors are driving the cesarean rate ever higher. Rates approaching—or exceeding-- fifty percent are now seen in some hospitals (New Jersey Star-Ledger.) This is the normalization of deviance. This is the new normal.

It would be unfortunate enough if the push toward CS were limited to a few upper-middle-class women (“too posh to push.”) But, judging from the South American experience, everyone wants the lifestyle of the rich and famous. Cesarean rates as high as 80% among well-off women in the private sector in Brazil (Kilsztajn 2007) appear to have created prevalent expectations, either among physicians or among other groups of women, that cesarean is the preferred option. (Potter 2008; Behague 2002; Angeja 2006) In at least some cases, poor women have been known to put away their own funds to ensure they will be delivered abdominally rather than vaginally. This would suggest they are concerned about inequitable or unfair treatment unless they deliver by cesarean. In the US, we have heard arguments that women are entitled to autonomy in making their birth choices, and that therefore it is ethical to perform cesarean for no reason other than maternal request. Curiously, this vaunted autonomy stops at the door of the labor room. Women are implicitly allowed, or encouraged, to make only those choices which increase the power of the physician and which decrease their own.

Let us enumerate what a full spectrum of childbirth choices entails. Women can give birth at home unaided; at home with family or with trained assistance; in a birth center, either freestanding or hospital-based; in the hospital delivery room with trained assistance; or in the operating room where they are acted upon. But of all these choices, extending across the entire range of reliance upon the medical profession (from none to total), exercising the options at the end of the spectrum where the physician has the least sway will get women the least support. The American College of Obstetricians and Gynecologists calumniates not only women who want a home birth but anyone who advocates leaving that option open. (American College of Obstetricians and Gynecologists, 2008.) Once in the hospital, women who might like to exercise their right to self-determination by choosing vaginal birth after cesarean, or vaginal breech delivery, will have a hard time of it. (Leeman and Plante, 2006) Is it not the opposite of autonomy to support only those choices which increase the woman’s reliance upon the physician?

Industrial obstetrics strips the locus of power definitively away from women. The history of childbirth in America reflects a persistent trend of increased control by physicians and increased medicalization. Childbirth moves, first, out of the home, and now out of the vagina. Stipulate that antibiotics and blood banks are good and necessary things, and that emergencies may, in fact, develop: still, the majority of births will be normal. Or they would be, without interference. The species that cannot birth its young becomes extinct. But fear has pushed nearly all American childbirth into the hospital, a campaign which continues even now that that battle looks to have been won. (American College of Obstetricians and Gynecologists, 2008) Still, despite the implied promise of safety if all the rules are followed—ID bracelets, intravenous lines, electronic fetal monitoring---labor may follow an unpredictable path. The definition of “normal” becomes ever narrower, and toleration of deviance ever lower. The final stage of this philosophy takes the process of birth away from the woman entirely and turns it into a surgical procedure performed by the doctor. Childbirth becomes a manufactured experience, shorn of any real risk or real power, one in which the woman is so far alienated from the capabilities of her body that she is only a package on an operating table for a professional to open.

We’ve seen industrial revolutions before. The classic example gave us cheap toys and manufactured goods. At first the consumer focuses on the price point and on the sheer reproducibility: every Thomas and Friends wooden railway toy is just like every other. When you reduce variation, you get “normal,” by anyone’s definition. The very notion of quality control is rooted in the factory. Economies of scale and industrial production give consumers cheaper product than the handcrafted item, so that just about anyone can afford to buy toys from China. (Unfortunately, cost is an issue for manufacturers too: lead paint is cheaper than the alternatives, so nearly 2 million of those Thomas and Friends wooden trains were recalled for safety concerns last year. Sometimes safety is trumped by other considerations when industry rules.) While industrialization reduces cost and reduces variation, it is not an unqualified good. Should we be so quick to cheer the industrialization of childbirth? (Gawande, 2006)

The industrialization of food production is, perhaps, a harbinger of the industrialization of childbirth. Food production was once local, varied and small-scale, but farms have been taken over by huge conglomerates, and monoculture of a small number of genetically uniform crops has replaced variety. The disappearance of cultivars—that is, the loss of deviants—means that random natural events could wipe out large swaths of the food supply. To draw an even more pointed parallel, meat in America is cheap and widely available because of industrialized animal production. These animals lead narrowly confined lives from conception to death. Reliance on a small number of breeds, confined animal feeding operations, and the production line essentially turn animals into factory products. Industrial animal production has exacted a price in ways that until recently were invisible to the average consumer: the pollution of air and groundwater, the increasing potential for foodborne illness, the escalation of antibiotic resistance which begins in industrial herds but moves into human populations, even the quality of those animals’ lives. Clearly, industrialization has a downside, although we may not notice the drawbacks until all competing models have vanished. While some would object to drawing an analogy between industrial food production and industrial childbirth, I submit that in both cases we see a conversion of a living creature to a commodity, with an emphasis on the end product and a marked disinterest in the natural process over time. Women can be processed through the childbirth machine and handed a baby at the other end, stripping them of their central role at the heart of things, and turning them instead into objects that someone else operates upon.

The paradox is this: women wish to be treated as individuals, and assert for themselves a wish to exert control, yet in the commodification and industrialization of childbirth they are so much more likely to be treated as units of production. I know of one large community hospital revamping their labor floor and planning for a 50% cesarean delivery rate: and just as we learned in the 1989 movie, Field of Dreams, if you build it, they will come. The staffing and scheduling patterns for a 50% cesarean rate, as well as administration plans for hospital length of stay, can’t be turned on a dime. Hospital administrations like predictability, in patient patterns, patient care pathways, and everything else. If we normalize this industrialized approach to childbirth, we are likely to be stuck in it for a very long time indeed—and we can’t look to the medical profession to correct it.

But maybe, just maybe, there’s a backlash coming. An entire generation of American women fed their infants artificial formula because they were told it was modern, convenient, and better for their babies. Decades of medical progress later, two-thirds of mothers at least attempt breastfeeding. (Wright 2001) The women’s movement has challenged the hegemony of the medical profession in the past. (Kaiser and Kaiser, 1974)

As a reaction to industrial agriculture and food marketing, the Slow Food and locavore movements have recently been born. If de-escalation of our food production practices is healthier or more humane, why is intensification of our child production practices better than sustainable childbirth? I’m waiting for the birth of the revolution, or at least, the revolution of birth. Will women who are interested in Slow Food or cage-free eggs find their way to a Slow Childbirth movement? Imagine: educated upper-middle-class women who buy songbird-certified organic coffee and worry about their carbon footprint, just saying no to the quick-fix cesarean culture. If they’re not part of the problem, maybe they can be part of the solution. But the impetus must come from women themselves. Do we really believe that industrial obstetrics is the best model for ourselves and our children? We must clearly understand that real autonomy does not mean cesarean on request, but instead a spectrum of birth options that honor women’s authentic choices. Real autonomy also means, to borrow a sentiment from Gandhi, that women should bring forth the change they wish to see in the world.

References

Althabe F, Sosa C, Belizan JM, Gibbons L, Jacquerioz F, Bergel E. 2006. Cesarean section rates and maternal and neonatal mortality in low-, medium-, and high-income countries: an ecological study. Birth 33 (4): 270-7.

American College of Obstetricians and Gynecologists. 2008. ACOG Statement on Home Births. News release, 2/6/08. Online at http://www.acog.org/from_home/publications/press_releases/nr02-06-08-2.cfm. Accessed 3/20/08

Angeja ACE, Washington AE, Vargas JE, Gomez R, Rojas I, Caughey AB. 2006. Chilean women’s preferences regarding mode of delivery: which do they prefer and why? British Journal of Obstetrics and Gynaecology 113 (11): 1253-8.

Behague DP, Victora CG, Barros FC. 2002. Consumer demand for caesarean sections in Brazil: informed decision making, patient choice, or social inequality? A population based birth cohort study linking ethnographic and epidemiological methods. British Medical Journal 324 (7343): 942-7.

Centers for Disease Control. State-specific maternal mortality among black and white women—United States, 1987-1996. Morbidity and Mortality Weekly Report 1999; 48: 492-6

Denk CE, Kruse LK, Jain NJ. 2006. Surveillance of cesarean section deliveries, New Jersey 1999-2004. Topics in Health Statistics October 2005 (revised January 2006.) New Jersey Department of Health and Senior Services, Center for Health Statistics, Trenton NJ.

Gawande A. 2006. The score: how childbirth went industrial. New Yorker, October 9, 2006: 1-9, http://www.newyorker.com/archive/2006/10/09/061009fa_fact?currentPage=1, Accessed 3/21/08.

Gandhi, M. 2002. As quoted in "Arun Gandhi Shares the Mahatma's Message" by Michel W. Potts, in India - West [San Leandro, California] Vol. XXVII, No. 13 (1 February 2002): p. A34.

Goldenberg RL, McClure EM, Bann CM. 2007. The relationship of intrapartum and antepartum stillbirth rates to measures of obstetric care in developed and developing countries. Acta Obstetricia et Gynecologica 2007; 86 (11): 1303-9.

Hamilton BE, Martin JA, Ventura SJ. 2006. Births: preliminary data for 2006. National Vital Statistics Reports. 56 (7). http://www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_07.pdf. Accessed 3/21/08.

Kaiser BL, Kaiser IH. 1974. The challenge of the women’s movement to American gynecology. American Journal of Obstetrics & Gynecology. 120 (5): 652-65.

Kilsztajn S, do Carmo MSN, Machado LC, Lopes ES, Lima LZ. 2007. Caesarean sections and maternal mortality in Sao Paulo. Eur J Obstet Gynecol Reprod Biol . 132 (1): 64-9.

Leeman LM, Plante LA. 2006. Patient-choice vaginal delivery? Annals of Family Medicine. 4(3): 265-8.

MacDorman MF, Hoyert DL, Martin JA, Munson ML, Hamilton BE. 2007. Fetal and perinatal mortality, United States, 2003. National Vital Statistics Reports 55 (6). February 21, 2007.

Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, Kirmeyer S, Munson ML. 2007. Births: final data for 2005. Nat Vital Statistics Reports 56 (6). Online at http://www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_06.pdf. Accessed 3/28/08

McClure EM, Goldenberg RL, Bann CM. 2007. Maternal mortality, stillbirth and measures of obstetric care in developing and developed countries. International Journal of Gynecology and Obstetrics 96 (2): 139-46.

New Jersey Star-Ledger. 2006. Giving birth in New Jersey. http://www.starledger.com/str/indexpage/environment/default.asp Accessed 3/29/08.

Potter JE, Hopkins K, Faundes A. Perpetuo I. 2008. Women’s autonomy and scheduled cesarean sections in Brazil: a cautionary tale. Birth 35 (1): 33-40.

United States Census Bureau, 2006. Two-year-average median household income by state: 2003-2005. http://www.census.gov/hhes/www/incomeincome06/statemhi2.html. Accessed 3/21/08.

Wright AL. 2001. The rise of breastfeeding in the United States. Pediatric Clinics of North America 48(1): 1-12.