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Sunday, August 8, 2010
Who controls childbirth — expectant moms or doctors?
By Taffy Brodesser-Akner
updated 7/13/2010 8:21:38 AM ET
That I am pregnant again is an act of either incredibleoptimism or mind-blowing amnesia. As the sonogram technician squirts jelly over my abdomen for my 20-week checkup, I think it's the latter. Watching this baby, who the tech tells me is a boy, I am not caught up in visions of his future; I'm caught up in visions of mine. All of a sudden, I know with a certainty I haven't allowed myself to confront before: Somehow, I am going to have to deliver this baby.
Obviously, you say. But my first birth was traumatic, and although my son and I emerged fine, I lost a year seeking treatment for post-traumatic stress disorder and all thedepression, fear and anger it brings. I imitated mothers who seemed normal to me, cooing and tickling my son. In truth, I was a zombie, obsessing about how I had ever let what happened happen.
What happened is this: In my 39th week, I am induced because of high blood pressure. At the hospital, I am given Pitocin, a synthetic form of the labor-inducing hormone oxytocin, and Cervidil, a vaginal insert used to dilate the cervix. Within two hours, my contractions are one minute apart. I had lasted as long as I could without an epidural because I had read that they sometimes slow dilation. That's the last thing I need: I'm at a pathetic 2 centimeters. My doctor comes up with a solution for the pain: a syringe full of a narcotic called Stadol.
"It sure is," she says."I have a history of anxiety," I tell the nurse who has brought in the syringe, as I always warn any medical professional who wants to give me drugs. "Is this drug OK for me?"
It is not. Within 10 seconds, I begin hallucinating. For five hours, I hallucinate that I'm on a swing that's soaring too high, that houses are flying at my face. My husband has fallen asleep on the cot next to me, and I'm convinced that if awakened, he will turn into a monster — literally. I'm aware this notion is irrational, that these images are hallucinations. But they are terrifying. I buzz the nurse. "Sometimes that happens," she says and Purells her hands before leaving the room.
By noon the next day, 24 hours after I had arrived, I am only 3 centimeters dilated. The new nurse, a nice lady, tells me the induction isn't working. "Your blood pressure isn't even high anymore," she says. "Tell the doctor you want to go home."
When my OB comes in, I say, "I'd like to stop this induction, if that's possible. I'm worn out. I hallucinated all night. I'll go on bed rest, if you want. I just don't think this is working out."
"OK," he says. "Let me examine you. If you're still not dilating, we'll talk about going home."
My previous dilation exams had been quick and painless, if not entirely pleasant. This one takes a long time. Suddenly, it hurts. "What are you doing?" I scream. "Why does it hurt?"
"He's not examining me," I scream at my husband. "He's doing something!" My husband grips my hand, frozen, unsure.
I scream to the nurse, the nice one who had suggested I go home. "What is he doing?" She doesn't answer me, either. I writhe under the doctor's grasp. The pain is excruciating.
The first sound I hear is the doctor's directive to the nurse, in a low voice: "Get me the hook."
I know the hook is for breaking my water, to speed my delivery by force. I scream, "Get off of me!" He looks up at me, as if annoyed that the specimen is talking. I imagine him thinking of the cadavers he worked on in medical school, how they didn't scream, how they let him do whatever he wanted.
"You're not going anywhere," he says. He breaks my water and leaves. The nurse never looks me in the eye again.
Eleven more futile hours of labor later, I am exhausted and terrified when the doctor comes in and claps his hands together. "Time for a C-section," he says. I consider not signing the consent form, ripping off these tubes and monitors, and running. But the epidural I'd finally gotten won't allow me to stand up.
It's nearly midnight when I hear a cry. My first emotion is surprise; I had almost forgotten I was there to have a baby.
Women 'taking back' birth
I was desperate to find someone who could tell me what had happened to me was normal. To say, "You hallucinated? Oh, me, too." Or "My doctor broke my water when I wasn't looking. Isn't that the worst?" Nothing. Instead, everyone wondered if I'd liked my obstetrician prior to my delivery, if I had trusted him.
Now, I'd never loved my doctor. But I did value him. Although I'd found him patronizing — "Normal!" he'd shout at me, when I asked a question — I thought his assuredness might be a good antidote to my anxiousness. It seemed to work, until it didn't.
When friends asked why I didn't have a doula, an attendant who provides labor support, I'd tell them that I wanted the birth to be an opportunity for my husband and me to bond. But that's just what I told people. Really what I thought was that I didn't need some patchouli-soaked hippie chanting what a "goddess" I was while I tried to endure some terrible agony in peace. I didn't want someone judging me if I chose to have an epidural, and I didn't want someone I had to be polite to while I was in pain.
I also didn't have a birth plan, a document that outlines for your doctor and hospital exactly how you desire this birth to go. Sure, I had a plan for the birth: Have a baby using whatever breathing method I'd learned in the hospital's birth-preparedness class, maybe get an epidural. But I didn't have the piece of paper that so many of my friends have brought to the hospital with them. These documents include such stipulations as "I don't want any Pitocin," "I'd like to be able to squat," "I'd like to be able to eat during labor," "I'd like the lights kept low." They are rarely made up of crazy requests, but in my opinion, the very act of creating such a contract was to ignore what labor is: something unpredictable that you are in no way qualified to dictate.
I bring up doulas and birth plans because people who hear my story ask about these kinds of things. Did I consider a home birth? A midwife instead of an obstetrician? How about The Bradley Method, childbirth training designed to promote unmedicated, spontaneous vaginal births? The answer is no. I am not holistically minded. My philosophy was simple: Everyone I know has been born. It can't be that complicated.
The women who ask me about my preparations for my first son's birth — who imply with these questions that I could have prevented what happened to me if I'd been more diligent — are part of an informal movement of women who are trying to "take back" their birth — take it back from the hospital, the insurers and anyone else who thinks he can call the shots.
But hospitals aren't so interested in giving women back their birth. One nurse told me that providers usually honor postdelivery requests made in birth plans ("I'd like to hold the baby for an hour before he's bathed") but that stipulations dealing with labor and delivery ("I want only one medical professional in the room at a time") garner barely a glance. University OB/GYN in Provo, Utah, even has a sign that reads, "…we will not participate in: a 'Birth Contract', a Doulah [sic] Assisted, or a Bradley Method delivery. For those patients who are interested in such methods, please notify the nurse so we may arrange transfer of your care."
In Camarillo, California, St. John's Pleasant Valley Hospital banned certified nurse-midwives from delivering or assisting in the delivery of babies. And earlier this year in New York City, when the hospital that had served as backup for seven of the city's 13 home-birth midwives went out of business, the midwives could not find another hospital willing to work with them. Barak M. Rosenn, M.D., director of the division of obstetrics and Maternal-Fetal Medicine at St. Luke's-Roosevelt Hospital Center in NYC, told The New York Times that his hospital would not back up the home-birth midwives because "when they come to the hospital, it's already a train wreck."
I rolled my eyes at the doula-attended, birth-plan-clutching mothers before, but I am humble now. This question of whether I could have prevented my trauma has lingered in my mind since that day; now that I am pregnant again, it has become deafening. I have a chance to do it all over. Would I benefit from thinking more holistically? Should I bother taking back my birth?
The best-laid plans During my pregnancies, friends gave me two books; their spines are still barely cracked. The first is called "Ina May's Guide to Childbirth." It compiles 44 stories written by women who came through the birthing house at The Farm, a community in Summertown, Tennessee, cofounded by midwife Ina May Gaskin. Most stories talk about the loving environment in which these women experienced rushes (Gaskin doesn't like the word contraction, as it implies a closing rather than an opening of the cervix) and the innovative techniques the midwives attending them used. In a few accounts, the woman doesn't believe that her cervix will actually dilate, that she'll be able to push. In the end, she learns that, yes, her body was made for this.
The other book is "Your Best Birth" by Ricki Lake and Abby Epstein; it's an offshoot of their 2008 documentary, "The Business of Being Born." Their urgent message is that women who want to deliver vaginally can do so if no one intervenes. Instead, doctors and hospitals are doing all they can to "help" the laboring woman along … and failing. Inductions like mine, epidurals given early in labor, continuous fetal-heart monitoring — all of them have been associated with a higher risk for cesarean section. The result is an epidemic — 32 percent of U.S. births were C-sections at last count, the highest rate in our history. Individual surgeries may be medically necessary, but as a matter of public health, the best outcomes for mothers and babies come with a rate of no more than 15 percent, according to the World Health Organization.
Sam, a 29-year-old chef in Los Angeles, was five months pregnant when watching "The Business of Being Born" convinced her that hospitals could be dangerous and a home birth would be more meaningful. She and her husband found a midwife, a doula and a back-up OB and spent the rest of the pregnancy preparing.
After 24 hours of labor, Sam's contractions were two or three minutes apart, yet when her midwife examined her, she was only 3 centimeters dilated. The midwife gently told her that she was nowhere close to delivering, despite her contractions, exhaustion and pain. Sam asked to be taken to the hospital.
The change of scenery did her good. "At that point, I had been in labor for 40 hours," she says. "I entered the relaxed zone. The epidural took the edge off, and I kept it low enough so I felt my contractions. I didn't want to hear the beeping of the baby's heart monitor, so I had them turn down the volume. I was vocalizing, and I was breathing, and I was doing all those things that I wanted to do. It was a sacred space."
After her son's delivery, Sam passed out, having lost 50 percent of her blood volume in a postpartum hemorrhage. Needless to say, she was relieved that she was in a place where blood transfusions were readily available. Regardless of whether midwives and doulas are trained and certified professionals — Sam's were, and they did everything right — the unexpected can happen with even a routine birth. Still, Sam told me, "if I'd never lost all that blood, I probably would consider home birth again." As it is, she believes she will want midwife care at a hospital next time.
Mayim Bialik had a similar experience but came away with different beliefs. You may remember Bialik as the star of the '90s sitcom "Blossom." Now she's 34, a mother of two boys, ages 4½ and 2, and the "celebrity spokesmama" for a nonprofit called the Holistic Moms Network.
Bialik and I are very different. She not only avoided strollers for the first year of her sons' life, but she also shares a bed with them and has begun homeschooling. She can recall only two times when she left them with anyone other than her husband.
"We wanted to do everything we could to reduce the possibility of intervention," she says of planning her first delivery, a home birth. "A culture that encourages you to let someone else tell you when to push instead of feeling it yourself scared me. I wanted to have power over my experience. Not to be a martyr but because my body was made to do this."
Bialik's first birth didn't go the way she wanted. After three days of labor at home, she stalled at 9 centimeters, one short of the goal. Her midwife suggested they go to the hospital, where after a natural childbirth, Bialik's son spent four days in the neonatal intensive-care unit. "My son was born with a low temperature and low blood sugar, which isn't unusual in light of the fact that I had gestational diabetes," she explains. "I understand doctors need to err on the side of caution, but there was nothing wrong with my child. All of our plans for bed sharing, nursing on demand, bathing him — gone."
The experience was scarring. "I felt a sense of failure that I had to call my parents from the hospital," Bialik continues. "Yes, I know vaginal birth in the hospital is the next best thing to a home birth." She considers me, knowing my story. "It's not like when people have a C-section."
I point out that natural childbirth in the hospital — her "failure" — was my best-case scenario. But I also understand when she says, "Everyone is allowed her own sense of loss." She realized her vision when her second son was born at home.
The second time around I don't consider myself a candidate for a home birth. The risk of uterine rupture from an attempt at vaginal birth after cesarean (VBAC) makes it unthinkable. (Midwives in some states will attend an HBAC, or home birth after a C-section, but none of the midwives I interviewed would.) But I'm also not really interested in a home birth. After labor (or surgery or both), I think the hospital is a great place to be. A few days of people bringing your food, checking on your health and — unpopular as it may be to admit — taking your baby so you can sleep is a gift.
But I'm also not interested in another C-section. I have a suspicion that if my ordeal had not ended with one, I wouldn't have been quite so traumatized. A narcotic that made me hallucinate after it had helped so many others is bad luck. A doctor breaking my water without consent is something to write the medical board about. But a C-section — being paralyzed from the chest down while awake during surgery — was for me akin to being buried alive; it was torture.
So I'd like to attempt a VBAC, but I know that it doesn't always succeed. I have a new doctor — the 10th I interviewed following my son's birth — at a new hospital, and he has agreed to help me try. But my primary goal is more modest: not to be retraumatized. Even now, my heart pounds at the sight of hospital receiving blankets, the antiseptic smell of the maternity ward.
The common thread in Bialik's and Sam's stories that impressed me was how supported and safe they felt with their midwife and doula. Their husbands were there, but the women weren't relying on them for anything other than love. Perhaps I had put my husband in a bad position by asking him to be my doula, too. Maybe I needed a hired hand who had been down this road many times and knew how to protect me from the things my husband couldn't, the enemies we were too compromised to see coming.
I told four doulas my story. One spoke of how I had to "vindicate" my last birth. Another extolledaromatherapy and how it might have helped me dilate. All four agreed on one thing: What had happened was partially the fault of the doctors and nurses, but it mostly happened because I didn't trust that my body would be able to give birth. "When you trust yourself again," one said, "you'll be able to dilate."
By now, one movie, two books, four doulas and approximately 15 mothers had told me that my traumatic birth was my fault, the problems all stemming from my not believing in my body. But what if my body wasn't meant to do this? Just because I was born with all the parts doesn't mean I am able to conceive easily. Just because I have breasts doesn't mean I can produce an adequate amount of milk. And having a vagina doesn't guarantee that I am able to get the baby out through that particular body part. Would we ever tell someone whose liver has failed that it was because she didn't believe in it?
In an e-mail Bialik sends after our meeting, she goes back to my idea that some women weren't meant to have babies the holistic way. "There are those among us who believe that if the baby can't survive a home labor, it is OK for it to pass peacefully," she writes. "I do not subscribe to this, but I know that some feel that … if a baby cannot make it through birth, it is not favored evolutionarily."
I think about my appendectomy, back in 2003. Had I not made it to the hospital in time, I would be dead. What would it be like to refuse medical intervention? I'd call my family, say my good-byes. "I'm sorry," I'd say. "But I'm not evolutionarily favored. It's time for me to go."
This attitude, that everything was better back when there were no doctors, seems strange to me. C-sections, although certainly done too often, can save lives. Orthodox Jews still say the same prayer after childbirth that those who have been in near-death experiences say — and with good reason. A birth that leaves mother and child healthy may be commonplace, but it's also a miracle every time.
'A beautiful experience' As the weeks pass and my belly grows, I can't stop thinking about Sam. Her pregnancy was a sacred time, and she had truly looked forward to labor. Is that what I should try for — a meaningful birth, as well as an untraumatic one? At what point had people like Sam and me learned to feel entitled to a meaningful birth?
"I think that birth should be a beautiful experience," says obstetrician Kimberly D. Gregory, M.D. She's the vice chair of women's health care quality and performance improvement at Cedars-Sinai Medical Center in L.A. "It should be exactly the way you want it, and doctors should intervene only to preserve the health or life of you or your baby."
Naturally, one would assume that Dr. Gregory advocates birth plans. When I ask her this, she laughs. "We always say, 'If you show up with a birth plan, just get the C-section room ready,'" she says. "You get everything on that list that you don't want. It's like a self-fulfilling prophecy." Dr. Gregory led an unpublished study that compared women who took traditional hospital birth classes with those who employed Bradley-like training and a birth plan. The birth-plan group trended toward a higher C-section rate and more interventions. "There's a certain personality type that tends to be more anxious. Maybe the anxiety hormones themselves put them at risk," Dr. Gregory theorizes. "It seems that being open and honest and choosing the right doctor is probably a better option than writing everything down. Walking in with this list appears to set up an antagonistic relationship."
In light of this insight, I ask Dr. Gregory about doulas. I've found studies that say women who had continuous support during labor were 9 percent less likely to have a C-section and 27 percent less likely to be dissatisfied with their experience. "Doulas can be helpful," Dr. Gregory muses. "So can a well-informed friend. But depending on the doula's personality — how well she interacts with the care team — I've seen it be catastrophic."
As I'm leaving my interview with Dr. Gregory, my phone rings. It's another doula returning my message. I tell her my story, prepared for another lecture on believing in my cervix. Instead, she is silent. After a few moments, she tells me that she's sorry and that this doesn't have to happen again. I ask if we could meet.
When we do, I sit back and listen. Hearing her tell me how to avoid the problems I had before in practical, physiological terms — a healthier pregnancy, more exercise in my final months — I feel, for the first time since I found out I was pregnant, that everything is going to be all right. I want to remain someone who doesn't want a doula. Yet I find myself asking this kind, professional woman if she is free in mid-July. And later that evening, my husband and I pick out a name.
But. In the past three weeks, I've had the same dream. I'm in a field (I believe at Ina May Gaskin's Farm), and women in braids are dancing around me as my baby is born, painlessly, joyously. As I reach down, I notice my C-section scar is gone.
I wake up upset. Am I truly under the impression, subconscious though it may be, that taking back this birth will undo the damage of the last one?
"I don't understand this phrase 'take back your birth,'" nurse-midwife Pam England, creator of "Birthing From Within," a popular book and series of childbirth preparation classes, tells me. "Who took it? What would a woman tell herself it meant about her if she failed to meet the criteria she made up for 'taking back' her birth? I am concerned that this phrase, meant to generate action and a feeling of empowerment, may actually be generated by or feeding the victim part of her."
England is right: Having a childbirth that I deem successful this time will not change what I haven't overcome from the first. I try to find a way to make what my doctor and nurses did to me OK, but my mind rebels. I feel loss — no, theft — of an opportunity for me to have a baby the way so many other women do: a carefree pregnancy, a labor that could still go any way.
Maybe I'm not so different from the women I spoke with, after all. Bialik had a successful natural childbirth but felt like a failure because it was in the hospital. Women who had a C-section also used words like failure. Perhaps part of the problem is that our generation of women is so ambitious, so driven, that we don't know how to do anything without quantifying it as a success or failure.
According to Dr. Gregory, women are now requesting a C-section for their first birth, even without indication. "A lot of people are uncomfortable with the unknown," she says. Plenty of people are wary of C-sections by choice, from holistic moms to obstetricians. But isn't this, too, taking back your birth? Refusing to be out of control seems to me the epitome of taking it back. You don't have to have an unattended birth in the woods to be considered a real woman.
Deciding that you can't control the uncontrollable — and committing to that decision when you are, in fact, out of control — is also taking back your birth. It's what your grandmothers did. It's what their grandmothers did.
With this, I realize that I have already taken back my birth, but not as part of any movement. I have stopped judging women who take extra precautions as defensive and started to understand that everyone has to find her way.
I don't know how this story ends. I'm still not convinced my body was made to deliver vaginally. But here's what I do know: I will insist on kindness. I will insist on care. And I hope I will be open to being treated kindly. It's harder than it seems.
I have another hope, too. I hope there will be a moment when the noise of the nurses and the doctors and the doula will fall into the background. I will look down at my baby — whether he is handed to me on my belly or from behind a curtain as my body is sewn shut — and I will remember what I've known from the beginning, when I looked down at that plus sign and we were alone together for the first time. Before these questions wrapped around my neck, choking me for answers. I will know that I am his mother and he is my son. And maybe, in that moment, I will be ready to say that the only success and failure is the outcome of the birth, that we are healthy. I hope I mean it.