What is my role as a doula and childbirth educator?

As a member of the childbirthing profession, I am a member of a number of listserves and email groups online. This week, one of the groups erupted with such a discussion that the current moderator stepped down and the group is going to have to re-form anew.

The topic: epidural kits and discussing epidurals in the classroom.

Some argued that having epidural kits “normalized” the idea of an epidural and made it easier for couples to get one. Others argued that without discussing epidurals, you are not actually providing informed consent. I take the second stance.

I have come to the conclusion in my own life that decisions that are best for me may not be best for others. Decisions that are good for me NOW may be different than decisions I made in the PAST or different from the decisions I may make in the FUTURE.

What does this have to do with childbirth education?

I do not think the focus of all childbirth education should be a natural birth at any cost. I don’t think we’re ready for it here in the U.S.

Please, don’t get me wrong. I think every woman that absolutely can do so, should have a natural childbirth. It’s good for her and for the baby.

But if we focus childbirth education as an all-or-nothing, we lose the women who may be on the fence. When we alienate women, we only hurt ourselves. (This, I think, is a failure of the feminist movement. But that’s a whole ‘nuther ballgame).

There are plenty of women out there who think that they cannot possibly cope with the pain and other distresses of childbirth. These women need to be empowered, not made to feel that they are less of a woman if they have an epidural in their birth. If they are empowered with information, maybe next time they have a natural birth in the hospital (as difficult as that may be). Then maybe they have a homebirth.

The woman who grows as a result of all her childbearing decisions will be the biggest advocate for natural birth. This is especially true among her close friends and her DAUGHTERS.

I have been trying to think about it that way as I formulate my classes. I want to support women in whatever birth they choose, even if it’s not the birth I would have.

“You had an epidural? How did you feel about that?”

“Stadol? That helped you get through?”
 

“You did everything you could to breastfeed this one? What do you think about breastfeeding the next one?”

Women are nasty enough to each other as it is. Don’t let that come over into the curriculum realm…

A lot of times, I think, we as childbirth educators and doulas forget that this is not our birth. Two wise women on another list this week talked about this concept in a great way.

From Polly Perez - 

The Difference in Feeling Responsible TO and FOR

When you feel responsible TO others....

• You show empathy, encourage, share, confront, level, are sensitive, listen.
• You feel relaxed, free, aware, high self-esteem.
• You are concerned with relating person to person, feelings, and the person.
• You are helper/guide.
• You expect the person to be responsible for themselves and their actions.
• You trust and let go.

When you feel responsible FOR others....

• You fix, rescue, control, carry their feelings, don’t listen.
• You feel tired, anxious, fearful, liable.
• You are concerned with the solution, answers, circumstances, being right, details.
• You are a manipulator.
• You expect the person to live up to your expectations.

There is such freedom in that! (This kind of freedom is why I got out of teaching public school. I’m not wholly responsible for this kid’s A or F. His parents and he are responsible as well.)

My job as a doula or childbirth educator is to inform. As a doula, I consider this to be very secondary unless the couple also hires me as an educator. I can’t make anyone want to learn and find out and question. If you’re not satisfied with every single thing your care provider suggests, I can point you in the right direction and show you where to find information for your truly informed consent. But I can’t make you read it. And I can’t make you ACCEPT it. As a childbirth educator, I can present that information to you, but again, I can’t make you ACCEPT it.

We need to keep informed choice at just that – CHOICE.

As a side note, but very related to the idea of choice, here’s an article about the availability of midwives and how it changes maternity care for the better. Note – it doesn’t say choosing a midwife, but just that the choice is available. I think all women with normal pregnancies should be seen by midwives, but again, we’re not there yet…How I hope we are soon!

Access to Midwifery Care Improves Outcomes

Birth in America - affecting the whole family

I believe the pervading culture of medical birthing in America has directly attacked families. As childbearing has been increasingly hospitalized and medically controlled, families have become smaller and smaller. Breastfeeding has decreased. Many couples are even choosing to have no children at all.
 

Why, as a culture, would we ever accept someone else dictating how big or small our family should be?
 

This is, in effect, what has happened with America today. Of course, my OB has never directly said to me, “You should only have two kids. Maybe three if the next is also a boy and you want to try for a girl.” But in his advocating a cesarean section for a first-time mother with a frank breech baby could easily dictate my family size.
 

How can this be?
 

Think about it this way. What if I were a regular birth consumer, one who takes her care providers advice at face value without probing? What if I then find out my OB doesn’t support VBACs, or he finds a way to “risk me out” of one? After a second cesarean section, my recuperation is probably more difficult – I have another child to deal with the second time. Breastfeeding is also more difficult, and the first section had complicated matters enough that I hadn’t continued breastfeeding the first. Maybe, as a regular consumer, I don’t even try the second time. I may do formula again, driving up our personal living costs, and taxes – we receive WIC vouchers. Even if I do pull through and breastfeed, think of the unnecessary stress and hardship a second cesarean, probably not done for any reason other than a previous cesarean, would put me through.
 

Why would I ever put myself through this again for even one more child?
 

As a culture, we need to realize that many times birth is traumatic and unnecessarily so. Women who have a traumatic vaginal birth for their first child are much more likely to request an elective cesarean for their next birth. If traumatic birth seems to be the only option, why voluntarily go through it again? The United States has some of the highest rates of permanent “birth control” in the world. Obviously, plenty of women are deciding it’s not worth it.
And I think the mode of birth can (though of course not always) have a direct impact on childREARing.
 

Again, think about it – we know that women who have traumatic births are at substantially higher risk for post-partum depression than women who are satisfied with their birth. Though women who have emergency cesareans may come to accept it or say it was for the best, I truly doubt you could say those women ever come to the point of feeling satisfied about that mode of birthing. Traumatic vaginal births fit in here as well. A woman may decide her nightmare of an induction was “medically necessary,” but it will never feel her with happiness.
 

And, women who have post-partum depression and/or traumatic birth are at higher risk for abusing their children. I’m not in any way attempting to justify child-abuse in any situation; we need to acknowledge these facts.
 

I believe that it doesn’t have to go as far as that even to affect the family. You can think of it like a continuum. Even if a woman doesn’t get to that point of actual physical abuse (or emotional abuse) or even to the point of post-partum depression, that dissatisfaction with the birth can subconsciously effect the way you raise your children.
 

As more and more births took place in the hospital, more and more women chose to enter the public workforce. Women go back to work for a variety of reasons, including both financial necessity and needing a “break” from the kids. At the same time women really begin entering the public workforce you see communities like The Farm with Ina May Gaskin where women chose to work within the family to provide extra income. While there is much more to that phenomenon than birthing, we can’t forget that birth certainly must play a role in it.
 

Birthing is not something you can just forget about and get over.
 

It’s coincidence that if you tell a woman you’re pregnant that you will hear every detail of her birth and pregnancy. This is the way it should be. Pregnancy and birth are life changing events every single time they take place.
 

Unfortunately, it seems that most of these details are negative. These negatives are by no means a small portion of the birthing population. It’s not that the few women who have bad experiences are the only ones speaking up. The vast majority of women seem to have negatives associated with their birth and pregnancy – scares in pregnancy, misdiagnosis, traumatic births, repeat cesareans.
 

Now you may say that families are smaller and more women working outside the home because of the advent of birth control. However, birth control methods have been around for thousands of years. Women knew and understood their fertility, when they were possibly fertile and when they weren’t, and they used herbs and timing to enhance or even suppress their fertility. Women in some cultures even used herbal preparations to bring on permanent sterility.
 

We also acknowledge that more children meant more workers for farming. We forget that more children also meant more mouths to feed, more bodies to clothe, more girls to provide dowries for, more boys to find apprenticeships in an already struggling household.
 

And families were still large.
 

I believe that if we fix the birthing environment in America, women and families will feel freer to have more than just “one of each.” There will be plenty of families who will still desire only one or two or three or even none and feel complete as a unit, but those families who desire more will feel free to have as many as they desire.
 

Children are a joy and a blessing. Feel free to complete your family.

For further reading - I have heard very good things about the following book. I'll admit that I haven't read it; I started it and got too emotional. It hit too close to home.

Weight Gain in Pregnancy...How much is enough?

American women are probably some of the worst regarding obsession with weight, and it’s unlikely that this obsession will diminish any time soon.
 

But this obsession among pregnant women needs to stop. Now.
 

I’m amazed at this phenomenon among pregnant women, particularly among women who otherwise are focused on having a healthy pregnancy. We scrutinize ourselves religiously – “Am I putting on too much weight?” though we never ask if we’re not putting on enough… We brag that we haven’t gained any weight by week ‘x’ in our pregnancy. Our friends even join in – “I would be sooo happy if I were as small as you are at ‘x’ week in pregnancy!”
 

Excuse me?
 

Maybe we’ve forgotten the facts. Or maybe we haven’t heard them.
 

For the woman of average weight/BMI pre-pregnancy, an increase of 25-35 pounds is considered normal. 25 pounds is the absolute minimum for the average woman. Underweight women should gain even more. Personally, I think these values are a bit conservative.
 

Let’s look at where this weight comes from. At 40 weeks, you should be looking at the following increases:

1. Baby  - 7 to 8.5 pounds (at least!)
2. Placenta – 2 to 2.5 pounds
3. Amniotic fluid – 2 pounds
4. Increase in the uterus – 2 pounds
5. Breast increase – 1 to 4 pounds (we forget that our breasts are not fully developed at puberty. They don’t fully develop until lactation.)
6. Blood volume increase – 4 to 5 pounds
7. Tissue fluid – 3 to 5 pounds (a little swelling is supposed to happen!)
8. Fat stores for breastfeeding – 4 to 6 pounds

I think fat stores of only 6 pounds are too low if you’re breastfeeding. For me, personally, it would not have been adequate. I put on 50 pounds while pregnant (yes, 50, just so you know it’s not a misprint), and would have lost every bit and more if we had continued breastfeeding.
 

As it were, I lost 31 pounds the first month postpartum. I had a very high supply and a healthy, hungry baby. If I were average weight pre-pregnancy, had put on only 25-35 pounds, and lost like that postpartum, I would have plummeted into the underweight category and put myself (and my son as long as I was breastfeeding) at health risks. It’s not worth it to look skinny.
 

In all my research, I have found little to no evidence in order to be concerned with weight gain above the guidelines of 25-35 pounds (apart from gestational diabetes) as long as you eat well. If pregnant women eat healthy – fruits, veggies, whole grains, lean protein, good fats and oils – they will gain the amount they are meant to gain. Our bodies, in the vast majority of cases, know what to do.
 

Inadequate weight gain increases the risk of preterm birth and small-for-gestational age infants. Maternal and fetal risks increase in these cases. Having a small baby does not equate easy birth. Smaller babies may have more trouble feeding, even bottle feeding, and a harder time sleeping well and keeping adequate body temperature. Is it worth it to be skinny a few months later?
 

Even if total weight gain is adequate at the end of pregnancy, inadequate gains during either half can increase your risks. Inadequate gains in the first half of pregnancy can increase your chance of a small-for-gestational age baby; inadequate gains in the second half can increase your risk of preterm birth.
 

So eat! Eat well! Eat only when you’re hungry and eat nutrient rich foods. Your weight gain in pregnancy is meant to provide for your little one both now and later.
 

It’s supposed to be this way.

A couple of notes:

1. Of course, I’m not advocating that you eat whatever you want, as much as you want, whenever you want. Obesity and excessive weight gain during pregnancy present their own sets of risks. However, I’m a firm believer in the theory that if you eat well, you’ll gain what your body is meant to gain.
2. The facts in this entry are taken from ready the following nursing textbook. This blog is factually based and any opinions present are based directly on my knowledge of current research and personal experience. The source is – Maternity and Women’s Health Care. By Lowdermilk and Perry

Servant Heart

Everyone questions their ability from time to time. I’ve been doing it a bit more often since last weekend’s Homebirth Meetup.

It’s easy to be intimidated. Many of these women are much more experience in birthing and breastfeeding than I am. Even the ones who may just be getting started at least have personal experience to lean on.

Now, I’m confident in my skills. I’m confident of my learn-while-doing abilities. I’ve been fortunate to acquire plenty of book knowledge and am just waiting to try it out.
 

But I have other experience that others don’t have. I’ve spent my life in the servant role.
 

My younger brother has severe autism and mental impairment. He now has 24-7 in-home care, but there were definitely some long hours when he and I lived at home. You do what you have to do so his needs are taken care of.
 

I’m a mother. We could, of course, leave it at that. When I think of the mother role, I often think back to a scene that happened a few months ago. We were at our friends’ home, having dinner, when an unexpected guest showed up. “I’m starved! I haven’t eaten all day!” And he sat down to devour some dinner with us. I turned to my husband and whispered, “what so special about that? I can’t tell you how many days I’ve had to do that with our son. It happens.”
 

But, of course, guys don’t deal with that kind of sacrifice as often or as naturally as women seem to do.
 

Women deal with those kinds of things all the time, whether we’re mothers or not. We’re the ones pitching in to take care of siblings, watching church nursery, working extra so our partners can go back to school, putting off our own dreams for whoever else needs them.
 

Those of us who find that this lifestyle comes easily often find ourselves in servant roles – teachers, nurses, caregivers, stay-at-home moms. I spent years, before becoming a stay-at-home mom, teaching middle and high-school students the finer points of English language and literature.
 

And I can’t discount those experiences. In many ways, they are just as valuable as personal birth experience.
I already know how to serve. I know to provide as much comfort as possible. I know I can’t take it personally when the person I’m serving rejects something I try – I just try something else. I can keep my cool through hours of crying. I’ve had students throw-up in front of me (while I was pregnant no less). I’ve changed countless adult diapers. I can put off my own bodily functions for an amazing amount of time. I know my limits, when I need take a well-timed bathroom break to breath, regroup, and keep going.
 

I can do this…

A Personal Story of Postpartum Depression Part Two

I finally decided to get treatment in April 2010, while we were in Mexico attending my brother-in-law’s wedding. I had several breakdowns on the trip and finally had the opportunity to really talk to my husband about it.

When we got home, I called a local therapist for an appointment. The first meeting went well, and she suggested I go to my family doctor for a prescription since that had helped me in college. I did, and things seemed to get better for awhile.
 

I stopped attending the therapy sessions though for a couple of reasons. I knew that the stresses of life and of my marriage certainly had contributed to the problem of my depression, but I didn’t like feeling that I was defending my husband during my counseling sessions. If I said that I trusted him, that we were working together, and that things were getting better, I felt that should be enough. Pushing him to come to counseling as well would not make things any easier for either of us if it wasn’t something he was comfortable with or ready for. Beyond that, it was difficult for me to get childcare and a way of getting to the therapy sessions. In the back of my mind I kept thinking about the cost, as we were already struggling to pay bills.
 

I continued to do well for awhile without therapy, relying on my own coping skills and the medication. I was on a fairly low dose, but looked forward to doing well without medication.
 

I’m not there yet.
 

In the past few weeks, my symptoms have reemerged. I found myself up at night, either forgetting to eat or binging, snapping at my husband constantly, and sitting on the recliner all day. It took me a couple weeks to notice the problem, but I quickly got in to see my doctor again. He suggested a medication increase or medication change. I asked to have blood work done first to rule out thyroid problems or anemia, which he was happy to do.
 

Fortunately, my blood work was clear, so last night I increased my dose as directed.
 

Unfortunately, I was up half the night.
 

Without sleep, I feel much the same. I can’t get anything done during the day due to exhaustion. I eat constantly, or forget to eat, because my brain is half down trying to cope. I’m irritable because I’m tired. I understand that medications can take 2-4 weeks to adjust, but this is madness. I don’t like being on medications either way, and being on a medication that I feel causes just as many problems, well, it doesn’t work for me.
 

I resolved one thing last night while I was lying awake – to look into alternative therapies for postpartum depression. That’s my goal for the next couple of days.

A Personal Story of Postpartum Depression Part One

It has certainly been a long couple of weeks for me, as you can see evidenced in the relative lack of blog posts.

So, in an effort to make good come out of this time, I'm going to talk about a very personal struggle.

I was diagnosed with depression in May 2010, nearly ten months after my son was born. For that ten months, I suffered in silence. I want to share the story of my struggles so other women won't have to do the same.

Going into the postpartum period, I knew I was at high risk for postpartum depression.

• I had been diagnosed with depression before, when I was in college.
• My previous depression was linked to a drop in progesterone - it would now probably be called premenstrual dysphoric syndrome because it centered around my periods.
• I was under a lot of stress at the end of my pregnancy - I was quitting my job to stay at home, our income would be less than half of what it was previously, we were moving, our house wasn't finished, and we were having marital problems.
• I didn't have the birth I wanted. I had prepared for a natural, normal birth and got a c-section for a stubbornly breech baby (he's still stubborn, I love him). I wasn't in the emotional state (see above) where I could devote energy into changing providers and having a vaginal breech birth
• Our breastfeeding was terribly unsuccessful. I tried and tried, but we didn't have the help we needed.

I felt guilty about what I perceived to just be "bad days." I would sit around the house, letting dishes and laundry sit, starting at but not even watching the TV. He was such an easy-going baby, and I didn't understand why I was having such a hard time.

Some days I had no appetite. I had to remind myself to eat, though I usually didn't realize it until my husband got home and was ready for dinner. Other days I felt like I couldn't stop eating. I was starving and constantly had something in my hand.

When it got worse, I found my sleeping was affected. I couldn't fall asleep, couldn't stay asleep. I had always been a morning person, but soon found myself unable to get out of bed in the morning. I would lie awake for hours at night, my mind running wild with all the things I needed to the next day. Few of them got done.

The biggest clue was my personality. I'm certainly prone to frustrations, but have never been one to lose my temper. Now I found myself yelling for little reason, crying often and being unable to stop, and feeling the great need to throw and break things.

In my previous depression, I had struggled with thoughts of suicide. Unfortunately, those returned. One day I had to leave the kitchen because I found myself staring at a knife, just thinking about it. 

During this time however, I kept telling myself that it couldn't be postpartum depression because I had a lot of good days. I had days where everything was fine. I still liked to be with friends, to go out, to have fun. I hadn't lost interest in my favorite things, at least not all the time.

To be continued...

What to do?

I have been encountering more and more often this idea in friends that the doctor knew best and their body couldn't possibly have done it on its own.

I honestly don't know how to deal with this mentality.

Yesterday the story I heard involved cesareans done for fear of too large babies. First baby was born vaginally with no problems, but four weeks before the due date. Second baby labored through but never descended so they rushed down for a section. Third baby was a scheduled section because "we figured out she was just too small to birth a regular sized baby."

Now at this point the family is beyond childbearing. I chose to smile and nod, sympathize quietly.

I felt no reason to ask if with the second baby they had attempted position changes to have gravity help move the baby down. Whether they had waited for the urge to push. Whether they had an epidural that interfered with feeling and the birthing muscles.

It wouldn't have helped this mom. There are no future babies; no way to go back and change things.

But would it have helped her daughter?

I was one of those that grew up hearing the horror stories of her mother's births. I had been a vacuum-extraction baby, after the first vacuum broke. After my brother's birth, my mother was sent to Cleveland Clinic for birth floor repairs following bad tears with the two of us (that were probably improperly repaired). My mother dealt with it without drugs, but "purple pushing" had certainly done a number on her. It was the only kind of birth she knew.

In these situations, when do you offer information? I don't want to cause pain, to damage a friendship or relationship when later I may be able to offer more help. But I also don't want women to go through life and childbearing without the knowledge that it can be powerful. Without the knowledge that it can be fulfilling rather than terrifying.

What do you do? Comments are very appreciated.