I arrived home at midnight after being with my client, Marie, for 18 hours. The house was still and dark, thankfully, with all my boys asleep. In need of support, I emailed my doula mentor, Lisa.
“Would it be totally out of line to somehow let a potential client know I don't wish to work with her practitioner?” I gave Lisa the back-story, pressed send, then crawled into bed.
My own back-up doula loved this practitioner and admitted she found solace and security within his office during her second-trimester experience of loss. Marie was my 5th birth with him, and although I had faith in her education and motivation, I had some underlying feelings I could not deny: Four of those five previous clients had ended up with cesarean births, and the situations were similar, in that they were failed inductions.
As Marie’s due-date approached, her practitioner kept suggesting an induction. When she declined, he had her come to the hospital for non-stress-tests and biophysical profiles every-other day. As far as the tests showed, Marie’s baby was happy and healthy, enjoying life within the salty sea of her mother’s womb. The hours spent at the hospital were frustrating for my client. She was not able to rest and relax during the last days of her pregnancy, and her practitioner kept phoning her at home, scheduling more tests, insinuating that she needed to keep the baby’s health in mind, but then always ending his calls with, “But it’s your baby…”
Six days past her due date, he asked her to meet him at the hospital at 6 pm so he could check her cervix. When Marie’s practitioner arrived, he asked her mother and her husband to leave the room so he could examine her. Unsure of hospital protocol and their rights, the two stepped out of the room. When they were brought back in, Marie had already received Cervidil to begin an induction. She made the decision in haste, feeling pressure from her caregiver, but she acknowledged and accepted her choice.
I joined Marie and her husband, Craig, at 4 am. Marie had been vomiting for an hour – her body’s response to the pain was to vomit…and vomit…and vomit. At one point she said, “I just need to stop throwing up!” She did not get any rest that night. The next morning she requested Nubain, and then later, an epidural.
At about 3 pm, she began Pitocin. Marie and Craig’s baby did not tolerate this well, and the Pitocin had to be turned off. Marie’s practitioner said a cesarean would be their best choice; less-optimally, he added, was to give baby a break and try to continue the Pitocin, “But I am not hopeful that will work.”
Marie was devastated. “When I came to the hospital yesterday, I knew this was going to happen – I knew I would end up here, and yet I did it anyway.” She sobbed, she vomited, she let everything out she could. Craig and I sat close -- touching her, holding her throw-up-bucket – and listened to her pain. After a while, she was calm enough to seriously approach her options. Although I could not make this decision for them, I let them know they would have my full and unconditional support, whatever they chose.
All of this took about an hour. Craig and Marie decided to try the Pitocin again. She was at 5 centimeters, her epidural was providing adequate relief, and she felt with one more shot, if the baby continued to show signs of distress, they would know without a doubt a cesarean birth would be warranted.
Amazingly, Marie and Craig’s baby showed no more signs of distress. She had the normal peaks and valleys medical practitioners like to see in response to contractions. By 9 pm, Marie was instructed to begin pushing. Her practitioner came in, tried to guide her through, and then 20 minutes into it, left abruptly without a word to Marie or Craig. They were confused and felt like something was wrong, but the three of us continued our routine.
Marie’s practitioner came in about 30 minutes later, checked her again, and stated, “Baby is still at -1 station. You haven’t moved her at all.” He did this with no emotion, no encouragement, no trace of hope in his voice. Marie became almost hysterical. To know her strained efforts in pushing her baby had done not one bit of good was too much to bear. “Looks like it’s time for a cesarean. You can talk about it. I will be at the desk.” And he walked out of the room.
“I can’t do it, Craig – I can’t do it anymore.” By this point Marie was hooked up to no less than ten tubes, wires and an oxygen mask. She had been awake for almost 40 hours straight. She had been riding a constant roller coaster during this whole process –- in fact, she admitted later, since her 28th week of pregnancy when her practitioner first suggested she may need a cesarean birth. Beyond exhausted, I had noticed for the last few hours her eyes literally looked like she needed toothpicks to hold them open, like in the cartoons. She had been vomiting again for the last two hours. Marie had reached the end of her rope.
“Marie, this is where you wanted to be – 10 centimeters! You need to just get angry, get mad, and push this baby out!”
I have never said that before during a birth -- “Get mad!” In the heat of things and my own exhaustion, it just slipped out. She shook her head.
This woman, this was not the same woman who sought out my doula services at 18 weeks of pregnancy. This was not the woman who read every good book she could find, books by Henci Goer, Ina May Gaskin, Marsden Wagner, Michel Odent, Penny Simkin. This was not the woman who watched The Business of Being Born and praised the information and prepared herself for a safe birth in the hospital. Where was that woman now?
Marie, the real Marie, was replaced by Marie-the-Exhausted, like a saint, or the title of a painting. Is it any wonder? Unlike a saint, or an objet d’art, Marie was a woman – a real woman -- trying to have a baby, right now, in the present. And to her perception, it was not working.
The information of her small amount of progress during that uncoordinated pushing was left out (she started pushing at 9 ½ with a very heavy epidural, and now she was completely dilated). When she asked, after her progress report, if there were anything her practitioner could do to help her push better, he said, “We could turn the epidural down so you can feel more pain -- ” To which she responded by vigorously shaking her head, like a toddler about to melt-down: “No. No. No. No. No. Don’t turn the epidural down!”
Craig went to tell their practitioner what they had decided. The practitioner came in, patted Marie on the head and said, “You ready for your cesarean then? I’ll go get the OR ready.” That was the first kindness extended to her in 40 hours – maybe 40 weeks! -- from the professional she trusted to care for her and her baby.
As things were being prepared for the birth, I was fighting back tears, telling myself over and over, “It’s not about me, it’s not about me, it’s not about me!” I watched Marie as she seemed to go deeper and deeper into herself in order to cope. I stood by, mopped her brow, held her emesis basin, and mentally absolved her from any judgment I may have felt for this choice. But I also detached, I know I did. I tried not to let this mother see it, but my heart stiffened and clouded over for what was happening here. And it scared me.
Baby was born safely with apgars of 10 and 10 (to which someone happily exclaimed, “Babies never get 10s!”). I stole a glance and a touch of the baby, hugged Craig, kissed Marie’s cheek quickly in the recovery room, and then left, much to the urging of her family and the hospital’s post-op policy. I walked out in a daze, unsure of what I was feeling.
That night, I had a dream about a swimming pool I used to frequent as a child. When I awoke, the image of that 22-foot deep end was still lingering in my mind. I realized something: Being with someone as a helper and observer during birth, you see many facets of the experience -- it's like you see down 20 of the 22 feet into the bottom of the pool. What must be determined is, how far into the water the mom sees. If she only sees 5 feet down, or 12 feet down, then that's where you must frame your references – you can’t go below her established depth, because it would do harm and not good. Even though I can almost see the bottom, if she can't, there is nothing to be gained by describing it to her. Throwing that stuff out there to her, without her asking specifically, would be a way of trying to comfort me -- it then would be about me, and not protecting her memory of the day her baby was born. How does this look in real life? When a doula brings up something that really bothered her, when she questions a decision the family made, when she offers her opinion about something the mother didn't bring up or seem bothered by -- that's when she casts doubt about the bottom of the pool the mother saw and basically tells the mother she is wrong.
So I shoulder and table a lot of things I remember and felt during her birth, which every doula should do.
Back to the question I asked of my friend: If I were approached by a woman interested in hiring me, and she had this practitioner, what would I do? Ethically, could I say no? To make matters worse, a week before Marie’s birth, I had committed to a client in just that position. I felt firmly lodged between a large rock and a very hard place.
The first (and easiest) option would be to inform the woman that I have not been comfortable working with that practitioner in the past, and to refer her to other doulas. Lisa cautioned, and rightly so, that this would need to be done in a gentle, diplomatic manner where I was not breaking the woman’s confidence in her practitioner.
The second option is a little trickier: I would tell the woman I am not the best doula for her situation. If this elicits more questions from the woman about why, I could ask, “Would you be interested in a few questions you could ask your practitioner?” Lisa shared, “Answers to how often he induces, augments, or performs cesareans may be revealing to the woman and can empower her to make her own choice as a result of her own research.”
The third option would be to put my personal feelings aside, just say “yes,” but with a motive: Taking this on as a personal challenge to help a woman have the best birth memories possible despite the way her care practitioner shapes the experience. “In this case,” Lisa said, “you do leave yourself more open to burn out.”
Remember the “It’s not about me” mantra? I have come to realize some element of this work does have to be about me. I love being a doula, and to keep my passion kindled I have to get even the tiniest bit of personal fulfillment out of it. There needs to be no guilt about this act of self-care and love. The doula/client relationship is similar to that of mother and newborn: There is a fierce desire to protect and nurture – the ratio is often 99 to one as far as what a mother gives to what she gets, and sometimes it’s about the same for a doula/client relationship.
It has been 10 years and many moves since this birth, but what did I chose to do? Out of Lisa’s suggestions, I did not feel one perfect fit, it more depended on how fit I felt. I would listen to the woman. I then assessed where I was emotionally and professionally. And then I would act accordingly.
Six months after Marie’s birth, I got an inquiry from a woman who had this practitioner. “This is our first baby. We have Dr. P., and we would really love to have your help through this experience.”
Guess what? I said “Yes.”
♥ four young boys and a boy dog (offspring)