Monday, March 31, 2008

The Contraction Question

“I don’t think I’m in labour yet. I feel it really low down, all in front. It’s not hurting ALL OVER.” said the doctor on the phone.

“ALL OVER?” I asked, sounding like a parrot.


“Um...if all is well, it shouldn’t.” I was just a little bit confounded. Here I was, talking on the phone with a physician who’s been attending births for years. She’s amazing with her patients, so intuitive. Now, in labour for the first time, she was just as confused as everyone else in labour.

“Um...” I decided to go over the "what do contractions feel like?" question. “Primarily, it should stay down very low, near the pubic bone, like menstrual cramps, getting gradually longer and stronger over time. It can give you that drag-your-bum-down feeling. You may feel a sensation of heat wash over you, just like you’ve opened a pizza oven. You may feel shivery on and off. You might feel nauseous. You might have it radiate to your lower back. Everyone experiences a variation on the theme. But, you definitely shouldn't have that “grab your tummy and crumple up in agony because it hurts all over pain” as seen on TV. That’s just drama for TV. Real labour is something that you already know on so many levels. And it’s not linear. It doesn’t just get exponentially worse like on TV. It ebbs and flows.”

“Yes, I remember you telling me that. But I didn’t believe you or all the other women. So,” she asked, “when we palpate the contractions of a woman in labour by feeling the top of her uterus, she doesn’t feel any excruiciating pain up there?

“Not in a normal labour. It’s only when there’s something wrong and the body needs to get the message across BIG TIME that you can feel pain in weird places. If everything's fine, you should just feel the contractions way down low...”

“So...uh...what I’ve been feeling all day might just be labour?”

“Probably. The start of labour is something that you will only figure out retrospectively. But, I can hear in your voice that you’re having contractions about every four minutes. You keep fading out. How about if I come over, and we can figure it out together...”

Well, to make a long story short, I went over to find that she WAS in active labour. Her lovely son was born only a few hours later.

Now, I don’t tell this story to poke fun at the doctor, but to show that, no matter who we are, we all have various ideas about how contractions may feel. We've been bombarded by descriptions all our lives. But these descriptions tell us more about the person who is doing the describing than about contractions themselves. Our perceptions are unique. So, whether we’re a family doctor with years of training and experience, or have read every book there is on pregnancy, or have listened closely to all our friends describe their experiences...our personal experience of contractions will be unique.

No matter what, even if this is your first labour, the contractions will be something that you recognize. They may not be what you expected, but they will be something that you "know" on a gut level. Hey, you're not going to get to age 30-something and then have the body throw you a complete curve ball, are you? Trust your body to let you know what it needs. As a doula, my role is to help you navigate your particular labour, no matter who you are, and what kind of labour you are "given". I try to help you shut down your 21st century brain, and accept the logic of the reptile brain.

And, wonderfully, that’s exactly what this doctor had done in her own labour...

I think one of the reasons she had such a smooth labour was because she didn’t NAME it “labour” until her body forced her to acknowledge it. She didn’t watch the clock. She didn’t waste emotional energy on waiting for labour to speed up, or to perform in any particular way. She just let it go, basically ignoring it, just like you would try to ignore cramps during a particularly nasty period. Who cares that she'd done all this because she was expecting something FAR worse than the reality.

I’m actually in awe of her way of getting through labour.

Maybe we should all try it.


Change. Is it always good?

In the next month or so, obstetricians at BC Women's will be changing their provision of care at the hospital. Rather than having three call-groups providing an in-hospital rotating OB consulting service (24 hour call, with each physician or midwife being able to choose one of the three available OBs, if a consultation is warranted, depending on the case at hand), there will be two obstetricians on hand (one primary and one secondary) at all times, each working 12-hour shifts, drawn from the combined pool of 20+ obstetricians that used to make up the three smaller OB groups at BC Women's Hospital.

When I heard about the change, I asked if caregivers would have a choice of obstetrician if they required a consult during labour. "No," said the head nurse, with a quizzical look. So, you'll just get who is available, not who might be the best "fit" (clinically and emotionally) for the client on that day. Even if an OB has been consulted during the pregnancy, if a family practitioner or midwife needs OB assistance in labour, they will be not be able to choose between the 2 OB's in hospital, but will only be able to consult the one who is designated for consultations. And remember, there will be one less OB in the hospital at any time. Hmmm...

I know that other hospitals have been using this one-OB-fits-all approach for years (e.g. St. Pauls - but they have a small pool of OBs, and a low-tech high-touch philosophy that seems to work well from the patient's perspective, and their nurses are given quite a lot of autonomy). At first glance, this change at BC Women's might appear to signal a departure from patient-centred care. But, apparently, improving patient safety was the primary motivating factor. So, it may be a good thing in the long run - the 12-hour shifts might result in more energetic OBs providing more focused patient care. But, the shorter work day (and the inability to chose the OB) could result a loss in continuity of care for the labouring woman. Could the positive working relationship between a family physician and a small OB call group be lost in this reorganization, causing further internal conflict? Who knows.

Will notice of this change be given to each woman prior to her decision regarding her primary caregiver for pregnancy, so she can make an informed decision about prenatal care? Now, this is a tricky question. Pre-conception information regarding "the caregiver decision" is already lacking in B.C., with many women making their decisions based on non-B.C. books or the internet. For example, many newly pregnant women don't know that B.C. midwives are covered by BC Medical (practicing in both home and hospital), or that the BC Women's "Birth Docs" are there for women whose family doctors don't provide obstetric care, or that, in B.C. (unlike the U.S.), obstetricians are not intended to be the primary caregivers of "low risk" women, but are consulted after a referral by a family doctor or midwife, if the pregnancy becomes "high risk".

As a doula, part of my role is to inform clients about their choices, their rights and responsibilities, and to help them to retain their autonomy. I'm also there to quietly remind them that birth is a normal life process. I do my best to provide my client with comprehensive information in a balanced and thoughtful manner, working in concert with their caregivers (many of whom I've known for 20 years). I certainly don't have all the answers to the questions that I've posed in this post, but a general wariness of change (I'm a Taurus, through and through) made me sit down to write this. Despite my feeling of unease, I'm going to have to sit on the fence with this one, and wait to see how it all works out.

To the obstetricians, it might look good on paper. But we'll just have to see how it works in reality....for the labouring women.

(Update June 11/08: The new system has been in effect for a while, and, while the obstetricians are well-rested and seem to have a new lease on life, I have witnessed some dangerous gaps in continuity of care when an OB is the primary caregiver of my client.)

(Update March 2009: Obstetricians are still voicing their concern about the 12-hour shift. Yes, they are well-rested and able to perform better in the OR, but some women have fallen through the cracks due to a lack of continuity of care. Some women may have three of four different OBs looking after them in labour, each with a different approach. No solution so far...)

Thursday, March 20, 2008

Persian New Year and "Fire Bum"

Last night was a perfect example of a final prep visit...with a bonus. When I walked into their living room I noticed some special items on top of a shelf, obviously placed with care. I could see potted hyacinths, coloured eggs, wheat sprouts, and more. The shining couple explained that it was Persian New Year, and that the altar held seven items that each symbolizes some aspect of rebirth and rejuvenation. I was honoured to be a guest in their home on this special day. It seemed fitting that we were talking about welcoming a new life into their home at the new year. Then, the cat jumped up and tried to eat the sprouts (to the cat it looked just like catnip, I guess...) So, ancient ritual and custom met the quirky reality of the animal world. That's kind of like how labour works...

On this second prenatal visit, always done in a client's home, I see the couple in their comfort zone. I also look for labour inspiration by seeing what's on their bookcase or what holds a place of honour in their home. After tea and a chat, we get active, and do a "birth rehearsal" through the rooms. Stick a glass to the wall and listen to my voice as we roam the house: "Oh! You can totally polish your hardwood floors with lavender wax in the last month - on hands and knees! That might help to keep things loose and, you never know, help to keep the baby in a good position. Oh, and that toilet is positioned perfectly so you can sit backwards on it in labour..." etc. etc... No, I'm not manic, just excited to show people how their body can move them through their own space in labour. It's quite fun for the couple, to see their home from this new perspective.

So, fast forward to later that evening. Here's the scene - I was demonstrating the "shaking the apples" move to them. "You don't just shake the hips, you rub fast, just like you're trying to make fire. You can feel the heat from the friction..." The dad took over and did it perfectly (I say perfectly, because she made little sounds of happiness.) "I'll call it Fire Bum," he says, smiling, and writes it down in a notebook. We all laugh! "Fire Bum!" A new name for this move is born.

We move through the apartment, with her trying out different positions (in this visit, we discover that she can lean on the kitchen counter AND slide her bum against the cool fridge at the same time - what a bonus in labour!)

I demonstrate the different power balance that happens when someone's standing above her, moving to her level, or kneeling at her feet. "Which feels better?" I ask. "Wow...what a difference...when you kneel at my feet it feels so good." She feels the power that will flow into her in labour as her partner holds her, their heads close together.

"But, watch the thumb wiggle," I laugh. I demonstrate and she shudders uncomfortably. "That's no good," she laughs. There is so much meaning in that thumb wiggle... So many times in labours around the world, there's a sweet man who places his hand on the labouring woman's leg (good so far), holds it there, pauses, then...starts to wiggle that thumb (yikes!!!) There's so much good intent in that wiggle - "I love you, I want you to be okay, it will be all right..." - but it just comes across to the woman (just on this one day) as fingernails on a blackboard. It sends the pain signals shimmering, expanding through her body. Yowzaa! A still firm hand, instead, acts like an anchor, sending powerful messages of safety and warmth through her body.

After two hours, all of their questions about the upcoming birth are covered, as well as trust, movement, honouring the body, non-verbal communication, back circles, mesmerizing back strokes (complete with waterfall images), rhythm and ritual (plus logistics - "Yes, you can really call me at any time, day or night!") They are ready.

So, I leave them at the door, a loving couple at the beginning of the New Year, so close to the birth of "a family".

Wednesday, March 19, 2008

The Baby is Breastfeeding - Not the Mother

Hot off the press! In the March 2008 issue of Birth, check out the article "The Baby is Breastfeeding - Not the Mother" by Dr. Lennart Righard. The ending sums it up:
"In natural birth the woman is moving around in upright positions trying to find the most comfortable position and turning to herself to find her own inner strength. Such a woman is not so easy to control! She follows her own impulses and intuitions and her own body’s signals. She relies on nature. The same is valid for breastfeeding. The mother does not know how much her baby is eating, she has to rely on nature. This is the secret of success in the triad of reproduction (coitus, giving birth, and feeding from the breast): rely on nature, relax and let go, and you will be amply rewarded."
Then, take some time to view the WHO/UNICEF Breast Crawl video. Perhaps we all need reminding that instincts work! - Jacquie Munro, Vancouver Doula

Renee takes it to the community!

Renee Hefti-Graham, lactation consultant extraordinaire, offers wonderfully information Breastfeeding Classes and Consulting in Vancouver.

I encourage all my pregnant clients to book a private or group breastfeeding class with Renee. She also offers an additional in-home breastfeeding consultation and phone follow-up service, if needed. Renee's comprehensive service provides incredible continuity of care, a vital ingredient in breastfeeding success.

Please call Renee at 604.733.6359. - Jacquie Munro, Vancouver Doula

("Maternite" by Paul Gauguin)

Tuesday, March 18, 2008

That's it! Time's up!

Love this sign! What a laugh!

But it does make me think about the very real anxiety that surrounds birth...and time.

When I initially ask clients what they wish for, the most common answer is, "A fast birth."

However, after we've been working together for a number of months, most clients realize that each labour takes as long as it needs - no more, no less. Each woman's task in labour is to accept its flow, allowing it to unfold as it should. Time and space start to recede, endorphins increase, tension starts to release, and then labour works well.

To put a time limit on any labour harms its natural rhythm. Birth is a psychosexual process. And, just like lovemaking, it withers when it is pressured by time.

Ultimately, once you understand the nature of birth and its relationship with time, you settle into a pace that fits you and your baby on this particular day. It may be fast. It may be slow. But, it should never be rushed or ruled by the clock.

So, don't be pressured by that sign...

- Jacquie Munro, Vancouver Doula

Monday, March 10, 2008

Body Surfing Mama

Well, we had an amazing and regenerating time on Maui. There are so many memories that will be treasured. But there's one that seems to sum up the incredible spell and power of Maui...

The other day, we were sitting on the sand at Po'olenalena Beach in Wailea, taking a break from snorkeling and boogie boarding. I looked up and saw a pregnant woman (she looked about 6 or 7 months...must have been having the "last fling" holiday) boldly heading into the surf with her husband, just glowing.

She lined up with the other couples trying out body surfing...waiting for that "just perfect" swell. She went for it on a big wave...and got totally tumbled in the surf. She came up for air, laughing and laughing, then bounded back into the water to wait for the next wave.

It was glorious to see her, tummy shining, fearless.

I sent her a wish that, on the day of labour, she draws on that fearlessness, and leaps into the waves just like she did at Po'olenalena Beach. the phone can ring again...