Week 28: The scary zone

Note: I started this blog with a few-week lag to my actual pregnancy, but that lag has turned into 10 weeks – thus the closely spaced weeks here. I’m trying to catch up…

Week 28 of pregnancy is a very scary zone for me. Before about 26-27 weeks, if I went into labor, god forbid, it would be very sad but would amount to a miscarriage or a stillbirth. Because a newborn cannot survive at those early gestations, there would be no hard decisions to make regarding medical care, as long as I was doing ok.

The scary zone is the time period when the newborn would be viable but would need immediate medical attention. Terrified as I am of hospitals, I could not stay away from the hospital knowing it could probably save the baby. It’s a pretty black and white situation, unlike, for example, birth between 35-37 weeks of gestation. That’s a gray area that would be tough for other reasons including not knowing whether my newborn would be one of the few needing real hospital help.

I pray for my anxiety to abate, and I am meditating. Thank god I have a hospital backup plan that seems ok and is developing.

Still I am getting something like flashbacks – I wouldn’t call them full on flashbacks but something more subtle. Intrusive thoughts maybe? Imagining myself walking in there, leaning against the wall for a contraction, nurses staring at me like I have three heads, masses of people in the room with me. I refuse to get on the bed. They can monitor me but I refuse an IV. Are they telling me I’m going to kill my baby? I want to point my butt toward the wall and protect myself in a defensive crouch.

My mind relives the scene of my first birth, like a rape scene, and fantasizes about what I would do if it happened again. If anyone came near me with an intent to force or penetrate, could I or would I actually fight them off? Would my husband or midwife be able or willing to prevent it? What if a well meaning nurse touched my shoulder with kindness – would I feel it as a slap? Would they chop the umbilical cord, leave me bleeding and deprive my baby of oxygen and her own blood volume, and then take her away from me for days and days?

Or what if I managed to fend them all off and they all stood staring at me, lined up against the walls of the tiny room, while I breathed my baby out? And then would I spend days in the hospital without my baby, or weeks going back and forth to the NICU, under their thumbs yet again, never knowing whether the invasions, drugs, needles, and prolonged separation were actually necessary?

These are nightmares, but the strangest thing is they only intrude sporadically. The rest of the time, I feel amazing, enjoying my growing belly and the happy hormones coursing through my body. The fetus is moving around and I’m starting to be able to distinguish specific movements and perhaps a limb here and there. It’s a strange mix of feelings.

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Week 27: More birth art

Birth art is amazingly freeing, revealing, and beautiful. The first one here is Door to Birth, from Birthing from Within, and the second is A Contraction, a suggestion from my husband (partly because he was really curious what contractions feel like!).

Door to birth

Door to birth

A Contraction

A Contraction

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Week 26: Birth art: Fantasy of Labor and Birth

This is one of the art assignments in Birthing from Within, called Fantasy of Labor and Birth. I would describe this picture as the fantasy to be cradled in nature, sheltered by a big tree and mountain, with no other people around, free and uninhibited – in this interpretation, I am the pink human figure. But a friend of mine looked at this and interpreted it differently. She said that she saw me as the tree, big and colorful and powerful and rooted.

Fantasy of labor and birth

Fantasy of labor and birth

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Week 25: Hospital birth plan

So as the OB recommended, I’ve come up with this hospital birth plan. It’s simple and explains what I most care about. Most consent and refusal of hospital procedures takes place verbally anyway, so I do believe that long written birth plans are best avoided even for planned hospital births.

Hospital Birth Plan

  • I am a survivor of abuse. Please do not touch my vagina at any time.
  • I will graciously document my informed refusal of any procedures and policies.
  • Please do not shout. Please limit staff to one nurse and no students or observers.
  • I welcome the assistance of a social worker or patient representative.
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Week 24: Having rights should not be a marker of privilege

Still trying to sort out my visit with the OB. I think it’s important to separate all the feelings I have after this meeting.

I feel elated at having been told that someone is actually going to go out of their way to take care of me and make sure I’m treated well, and satisfaction at hearing a doctor say that patients’ rights are unequivocally paramount. My understanding is that this is extremely rare in US obstetrics – maybe all of medicine – and I feel lucky that this doctor is in my area.

I also know that if the culture of the hospital respected patient rights so well, he wouldn’t have felt it necessary to give me his cell number, and it gives me anxiety knowing that I could still be mistreated. One of the pitfalls of hospital birth, whether planned or not, is the large number of unknown people involved in any given birthing situation; each of those people is a wild card.

I also can’t help but be angry at the “specialness” of my special treatment because it should have been available to me the first time. This kind of respect should be the status quo and not just the province of people traumatized and determined not to let it happen again, not to mention people with the privilege and resources to engage in these conversations. Even though I now personally feel protected, it’s the exception that proves the rule. Most women giving birth in this country, and in the world, don’t have the privilege of basic human rights – which should be the status quo and not a privilege.

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Week 23: Meeting with hospital OB

This OB is amazing. He said the specific words “patient rights trump protocol” and he really, really meant it.

I walked into my meeting with him fully expecting to get some bland reassurances, maybe some talk about how every doctor there is just fine, home birth transfers are treated just like everyone else, etc. Instead I got an empathetic, down to earth guy who is apparently trying to change the culture of the entire hospital.

Not only does he firmly believe in patient rights and the right to informed consent and refusal, he is trying to infuse the hospital culture with that belief, down to every resident.

During our meeting he told me a story about a woman wanting a VBAC after multiple c-sections. He ended up taking it all the way to the top to make sure she would not be coerced or forced into a repeat c-section unless it was necessary. (She got her VBAC.)

He gave me a bit of a puzzled look when I asked about nurses – he thought it was an irrelevant question because nurses aren’t the ones doing most of the procedures I would refuse such as vaginal exams. In retrospect, it makes sense that some doctors don’t know a lot about the coercion and abuse that nurses perpetrate in the name of hospital policy. But he said informed consent is “sacrosanct” among hospital staff: “If you don’t have consent, you can’t do it.”

I feel like I have just met someone who actually wants to take care of patients. He wants to take care of people and meet them where they are. He sees himself as a steward of good medicine and good relationships and is trying to spread that throughout the hospital.

He said the hospital hasn’t had much opportunity to test how it handles home birth transfers because so few midwives feel like it’s a place they want to bring their patients. He acknowledged that “a lot of hospitals still have a reflexive negative reaction to transfers from home that is frequently unjustified… It’s a clash of cultures.” But he is actively trying to change that. Because the change is in process and nascent at this point, he gave me his cell number in case I have to transfer, and told me it would be a good idea to make a written birth plan.

For the first time since my birth experience, I feel held, supported, heard by a human being within an institution. I feel like the professionals, the technicians, that I am working with now have a sense of me as a person, a sense of me as being important and of my unique desires being important.

This has been a serious breakthrough.

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Week 22: Words for the hospital and some for home

I could write these on cards, or just memorize them. Or I could look up this blog post should I need to.

“Please do not touch me.”

“I’m going to decline IV fluids, thank you.”

“I would like to decline that procedure at this time.”

“I will sue this hospital”

“Thank you for the information. We will let you know our decision.”

“I am exercising my right of informed refusal.”

“I understand your hospital’s policy of X and I decline.”

“Can I speak to the supervising nurse.”

Then there are some more interesting affirmation-type things I wrote in a journal. Riffing on the fundamental concept of my autonomy in all things.

My body, my choice.

My body, my baby.

I will decide what’s best for me and my baby.

I demand respect.

I decide when. I decide how. I decide if. I decide what.

I am a person.

I can invite, I can welcome, and I can banish.

I welcome and I bar the door.

My body is my house.

I surrender to labor but not to human fear, greed or violence.

My comfort level is the most important one.

I smile and politely refuse.

I can say “I do not consent to this.”

I can scream “Rape!”

I will take names.

I know a defensive stance.

I am running the show.

I don’t need anyone to walk with me, but I am happier in community.

I will seek, hear and welcome advice, but I may not follow it.

I will speak clearly when I say what I want.

Yes means yes. No means no. No is a word I can say whenever I want to.

I hold the power in the relationship.

I cannot compel – those who wish to leave may leave.

My wishes may challenge assumptions.

My wishes may try my advisors’ patience. If they fail, I can go alone.

I control what humans to do my body.

What God does, is God’s will.

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Week 21: The priority of safety vs. other values

A while ago a friend got me to thinking about the concept of “Safety First.” If we actually adhered to that principle, we’d never leave our houses, we’d never climb mountains, we’d never do sports, etc… There are so many things that we do in life where safety figures in importance, but is definitely not first.

In birth, where would I put safety? And more importantly, what would I prioritize ahead of it?

Personal bodily autonomy. This means that if increased safety is to be found in a place where my right to make decisions about my own body – including decisions affecting my fetus – will not be respected, I will not willingly go there. Luckily, I am beginning to believe that my backup hospital is not such a place, and that my autonomy would be respected, but I have heard of places around the country where this is not so.

There are many institutions that do not respect women’s autonomy; and there are people that will not respect it in spite of their institution’s stated policies. In studying this problem, both institutional policies and informal culture are important, and people with medical authority (ie doctors) as well as people without medical authority (ie nurses) have the power to violate this principle.

What does it mean for me to have my bodily autonomy respected? For example, if I go in hospital with a written birth plan that says “Please do not touch me anywhere without my express verbal consent,” it will be followed. For example, if I say I do not want an IV in spite of policy, I will not have one forced into me. For example, if I am unable to verbally consent because of being deep in labor, I will still not be touched if and until I am able to consent, and then only if I do.

Relationship. My relationship with my caregivers is one of the main determinants of my health and that of my fetus. If I were to gain a modicum of increased safety by handing over my care to someone with whom I have no relationship, I would not do it. If I were to gain my life by doing so, I would do it – so there definitely is a line.

One could have many philosophical arguments about where the line of “safety” falls. Some would say that a 0.5% decrease in the chance of a bad outcome warrants going against your principles; I disagree with that argument but would agree that say a 50% chance of death would make me go against them if I thought I could be saved. I am considering where my personal line falls, and the gray area is most difficult. Most likely if I went into labor at 36 weeks I would choose to stay at home with my caregivers, or alone with my family and community if they would not attend me. But what about 35? 34? The earlier we go, the more I’d be willing to give something up in return for greater safety for my fetus.

Gratitude. This does not conflict with safety but I feel it is important to mention. I want to conduct myself in pregnancy and labor with a sense of deep gratitude to my friends and family, my community, my body and the world around me. Any of those things, especially the world around me, could fail to protect me at any point, but I do not want to lose my gratitude.

Spirit. A hospital is a spiritless place most of the time. Some caregivers lack it anywhere. If I hadn’t found the midwife I did, and couldn’t find any that embodied spirit, I would have kept looking.

Safety. Without protecting ourselves against what we can foresee and prevent, we would be throwing ourselves away needlessly. I’d never do a free climb, or bike recklessly – taking basic safety precautions for those activities does not, in my opinion, interfere with any of the more important elements.

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Week 20: Reading Childbirth Without Fear

Childbirth Without Fear is a fascinating example of how a sensitive, compassionate and feminist man can support natural childbirth – and how that support, when coming from a man, does not equal the same support coming from a woman.

Grantly Dick-Read empathizes with women’s experiences giving birth in a way very few doctors, and very few people who haven’t given birth, can. He writes about how a piece of music, heard during a traumatic incident in his childhood where he heard someone being shot, could re-trigger the same feelings years later. His comparison between that triggering and what a woman may feel when re-thinking her traumatic birth is striking in its compassion and respect for the lifelong impact that a violent birth experience may have.

Likewise, his moving story of lying in a rehab hospital after the war, half blind and paralyzed, and hearing people say “at least you are alive!” virtually replays the ignorant “at least you have a healthy baby!” comments heard so often these days (and probably in his days, too). The nurse who holds his hand in silence and peace is a model for doulas and midwives, and he says obstetricians should give laboring women the gift of silence, peacefulness and undisturbed support too.

The book is wordy in true British style. It’s also extraordinarily well written and contains nuggets like this:

Each constituent of the ordinary is so extraordinary when understood. It is so in nature, in every sphere, one if its great fascinations. It is more thrilling to watch an avalanche crash in a cloud of snow to the bottom of a ravine, than to lie on the edge of a Norfolk marsh. Yes, more thrilling – until you have looked quietly and closely into the reeds.

or this:

Frequently fear and pain are initiated by the physician himself owing to his entire lack of understanding of the true significance of the phenomena of pregnancy and childbirth. It is difficult to give confidence when you have none; it is not easy to eliminate fear in another when you are apprehensive yourself.

This quote describes perfectly the attitude of many obstetricians I have encountered; whether they are afraid of a bad outcome, a lawsuit, reproach for violating hospital policy, or of something undefined, fear characterizes their every interaction with their patients. Combined with a lack of understanding of the stages of normal labor, and with the fact that few have ever sat with a woman in labor from start to finish, it is no surprise that most OBs increase fear, tension and pain by their conduct.

At the same time as I agreed with his ideas, a strange feeling bothered me as I made my way through the text. I only realized after I had finished the book that the same weird feeling dogged me all the way through Memoirs of a Geisha.

Memoirs of a Geisha is a novel telling the story of a traditional geisha, written in the first person. It was recommended to me as a true story, fictionalized, and I didn’t realize until the very end that it had been written by a man.

The weird feeling came from reading an account of women’s lives written by a male author. No matter how much he understood and appreciated the geisha character’s experience, he could not remove his patriarchal position of privilege and authority from his interpretation of her point of view.

And it’s the same with Dick-Read. I deeply sympathize with what he is trying to say; it’s clear he has made an important contribution; and he seems like a good person – but he is still a man. That fact removes him from his subject. It places him in an automatic position of authority, whether or not he wants to be there. And as a member of the patriarchy, he can only do so much to improve things. Don’t get me wrong, I think he’s probably doing all that he can from his position – but it is a position within a hierarchy that consistently places women at the bottom.

Perhaps this is why I want to remain a doula and feel apprehensive about the possibility of becoming a midwife one day – and why I would never become an obstetrician. No doubt I could do very good work in those positions, but I do not want to take up a position within the accepted structures of our patriarchal society. Speaking from that position, I would inevitably be speaking – at least in a small part – on behalf of the system.

Childbirth Without Fear remains an interesting historical document and should be read by those interested in obstetrical history. But let the women’s voices be louder. I’m talking about Ina May Gaskin, Penny Simkin, Sheila Kitzinger, Pam England, Sara Buckley, Ricki Lake, Robin Lim, and others – some birth professionals, some not. Their voices are the ones that should be amplified.

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Week 19: More musings on unassisted

I feel like considering whether to have an assisted or unassisted home birth, for me, mirrors the dilemma I see my doula clients get into when considering whether to have a hospital or home birth. Although prenatal care plays a huge role in that decision as well, and I am not on the fence about whether to have prenatal care.

The vast majority of my clients end up choosing the hospital. They look at the risks of home birth, which are small but real, and decide that they would rather pay for the promise of near absolute certainty with the discomfort, anxiety, unnecessary intervention, and possible c-section that they are welcoming by having their baby there. There ARE risks in the hospital, these people are extremely intelligent, and I don’t think they are ignoring those or unaware. They have simply made a decision that they would rather take the risks involved with hospital technology, in exchange for the benefit of having that technology close by if they should need it.

Likewise, I consider the risks of unassisted birth to be very small, but real. Having a qualified midwife in the room with me would mitigate some of those risks. I have to think about what the risks truly are, what the price will be and if I am willing to pay it to mitigate those risks.

On the other hand, I must consider that for me, safety is not first. If I feel absolutely driven to do something, even if it is risky, that might be the right decision IF I can accept the risks.

The question is, what am I really driven towards? Am I only fantasizing about going unassisted because I am afraid of other people’s meddling? Or is it truly what I think will be best for me and my baby?

Another consideration is that unassisted birth isn’t really what I want, but thinking about it is my way of acknowledging that I don’t fully trust the professionals. As in, at no point will I hand over decision making to them as I did the first time.

The funny thing is, I do believe I have hired the best midwife I’ve ever met. After all the mistrust I’ve expressed so far, I can also say that if there ever was a midwife who I could probably trust, and who would probably do whatever she could to protect me, and understand how to protect me, it’s her. So I am hopeful that I will very much want her there when I go into labor. But if I don’t want her there, that’s ok too.

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