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Sunday
Feb272011

Seizing Her Day

Mom was referred to me by another woman, a former monitrice (& friend) client of mine. But, instead of the usual help-me-have-a-better-birth type of doula, this mom was asking me to be a help-me-not-have-a-seizure-during-my-labor doula. Immediately, I knew I was up for the challenge. 

My client has epilepsy, diagnosed over a decade ago after reams of tests. While it is fairly well-controlled with medications, she has hair-triggers exacerbated by being out in the world. 

A note about her medication… her dose climbed to double the normal amount during the pregnancy. Neither of us could find any information about the safety of that much medication (even on Hale’s site) on the fetus and, very oddly, the OB nor the Ped were concerned enough to refer her to a neonatologist, which I suggested several times. Anytime she asked for a referral, she was told she’d see the Ped in the hospital after the birth and if there was any issue then, she’d be referred to someone. Does this seem weird to anyone else? She was aware (and I read a lot about seizure meds in pregnancy and postpartum) that her dose would fall precipitously postpartum. Within three days, her dose was already halved. During the pregnancy, her levels were drawn once a month to see how her body was metabolizing the medication; she metabolizes fast, hence needing so much medication. 

So, one of her main seizure triggers is scent; scents that aren’t even perceptible by others invade her brain with sensory overload. She told me that even very soft scents… vanilla, florals… things that many would never suspect as a problem, can be some of the worst offenders. Asking people not to wear perfumes is only half the battle, because so many of us have something that smells… our hair products, our deodorant, even our make-up… all carry the molecules that can send my client into the haze of a seizure. 

From what I know about my mom’s seizures, they aren’t the fall on the ground in paroxysms type, but instead, she loses touch with her surroundings, melting into the inside of herSelf, eventually recreating mental definition after unknown periods of time. For those of us who know labor and birth, this is not a good time to fall under the waves. In fact, the water metaphor is one of the most oft-used when talking about the intensity of contractions and birth and it works perfectly for my client’s experiences as well.

As doulas, one of our jobs is to be the buoy for our clients as they swim the Ocean of Turmoil that can be labor. Of course, not every woman feels this analogy is appropriate, but it’s great to describe the challenge of balance in a complicated labor such as this. As hard as it can be to keep a mom without epilepsy from allowing the surges to swirl her downward into the pain, with this mom, it becomes decidedly crucial to help her stay in her reality. 

During her last birth, six hours from start to finish, she was in a small town hospital with a General Practitioner as obstetric physician. She was one of two women who had a baby there during the entire week; the night she had the baby, she was the only woman there birthing. No IV, no medications, simply sitting quietly, mom was able to concentrate on her contractions, keeping her muscles relaxed and her mind focused. She told me that whenever someone talked to her, even inbetween contractions, it jolted her out of her peaceful state and it was work to get back in. 

As she described her previous birth to me, I immediately thought of a Hypnobabies/Hypnobirthing mama, that place they go deep inside, leaving an exterior of calm; it sounded like this mom figured out how to do the self-hypnosis without ever taking a class. (Ah, and how many others could if there weren’t shows like “One Born Every Minute?”) 

Over the years, this woman has had to ask a plethora of friends, family, strangers and even professionals to please not come close because she could feel herself leaning towards a seizure. With a straight face, she told me how, nearly across the board, when she’d explain the extreme sensitivity to their scent, not only the person themselves, but also those around her would say, “But, I don’t smell anything!” as if she was making it up. Or lying. Even in this pregnancy, one of the docs in the high-risk OB practice had a scent that caused my client to barely remember the appointment at all because she floated in and out of seizure activity the entire visit. When she asked not to see her again and explained why, everyone seemed terribly offended, which, to me, is a stunningly bizarre reaction. Apparently, her wishes were not distributed throughout the scheduling department and she, later in the pregnancy, found herself, once again, with the scented OB; this time, she chose not to say anything… they weren’t listening anyway. 

So, as my new client outlined my role as her doula; it was to 1. Keep the room quiet 2. Keep the room calm 3. Be the fall guy if someone needed to be excused from the room. Number three sounded especially fun. 

As a midwife, it’s not unheard of for me (and midwives in general) to be the “reason” for grandma not to be called when mom goes into labor… or to limit visitors postpartum… or to  <fill in the blank for a mother’s individual desire that can cause friction in the family if the her wishes were disclosed>. Being the heavy isn’t difficult for any of the midwives I’ve ever known. I’m sure doulas are called on to do this sort of thing at times, too, but many doulas, especially not terribly experienced ones, might be timid about ordering folks about. Even if they do it as sweetly as I do. batting eyes 

Mom’s care seemed odd to me at times… she being diagnosed with pre-term labor and put on bedrest until 37 weeks (not the odd part since her Fetal Fibronectin was positive at 34 weeks)… but once she hit the magical 37 weeks, it seemed as if she was prodded towards delivery as soon as possible. She had twice-weekly Bio-Physical Profiles, which, by the way, saw her amniotic fluid levels going up and down… pretty dramatically sometimes… from a seven to a twelve in a one week period. She did nothing different between the two appointments, showing the relative subjectivity of the measurement depending on the baby’s position in utero. In fact, two days before the delivery, by mom’s description, it sounds like the doctor stripped her membranes, saying, “Let’s see if this does something.” He then sent her to L&D to be monitored. 

Now, she’d been having contractions for many weeks by this 39 week visit, each NST raising eyebrows with the nurses and doctors; they never amounted to much, however. So, when she was sent to be monitored after (what I suspect was) her membrane stripping, there was nothing new to be seen… just the same fairly regular, painless contractions. In fact, mom couldn’t even tell the difference between the baby’s movements and a contraction, so when asked, she answered, “I don’t know.” You know that frustrated the hospital staff! 

After sitting in Triage on the monitor for a couple of hours, she was sent out to walk for another two before they were going to check her (do a vaginal exam) to see if there were any changes from the doc appointment earlier (where she was 2.5/50%/0). During her walk, I got a phone call telling me she wanted to go home, but they seemed to just want to keep her. She asked for reinforcements to tell them she wanted to go home, so I zipped up there and we went into Triage together. This hospital only lets one person at a time in Triage with mom, so her husband waited in the lobby downstairs. Mom was put back on the machine, her vitals taken (which showed her blood pressure and pulse interestingly high, by the way) and then the nurse did a vaginal exam. 2.5/100%/-1. “I don’t really know why your doctor sent you over.” “I want to go home.” “I think that’s a good idea!” She was un-tethered and we walked out about 15 minutes after I got there. I was glad she wasn’t kept because of the higher blood pressure and pulse, but was also curious why they didn’t address it. That sort of thing is a mystery about hospital care; how can some things slightly out of range make them crazy, but others that are wildly out of range seem like nothing to them? Very strange. 

We kept in touch over the weekend and then I was awakened Sunday morning at 5:40am (don’t you love Call History?), my client’s husband telling me they were heading into the hospital. I got up, showered, got coffee for dad and me, picked him up some breakfast and zipped over to the hospital. Dad ate in the lobby while I went up to hang out with mom –who was 4/100%/0… a lot of change since Friday! Once we moved to a room, her husband joined us again. 

Now my job began in earnest. 

Before we left Triage, I reminded the nurse that whomever we had could not be wearing perfume of any kind and that if mom commented on a scent that was offensive, the nurse could not take offense, but would excuse herself quietly and get someone else. “Absolutely,” she said. We talked about how she would go up one more floor to Labor & Delivery. I suggested she walk, but mom wasn’t sure how she would do that, so asked for a wheelchair. Then she walked to the bathroom a few feet from the “room.” Once out of the bathroom, she sat in the wheelchair and up we went. 

From the time I joined my client in Triage to when we got settled in the labor room (about an hour); her contractions went from seven minutes apart to four minutes apart. Oh, yeah… she was zipping right along. 

But, and this is the amazing part… when she had a contraction, all she did was look at the ceiling and breathe. Not heavy. Not hard. No moaning. No swaying. Just sitting quietly reclined in the bed, staring at the ceiling across the room. If this wasn’t a form of self-hypnosis, I don’t know what is. 

While mom was on the external monitors, she only had the saline lock. I really was surprised. 

The high-risk OB deserves a mention. He had to have been my son’s age (28 or so) and was a yummy Jock-looking guy. He had tattoos peeking out of his scrubs, so we all took a few minutes to show off our tatts. He had them on both arms and lower legs… and back (but we didn’t see that one). I really, really don’t know how the verbiage unfolded, but during this show and tell, I chirpily said “la-la-la-la-la (something I don’t remember) You’re cocky.” Hahahahaha… we all laughed and I could see the nurses stifling giggles and then, all of a sudden, I realized… I said that to a doctor! I tried to side-peddle and said something like, “Well, you are extremely handsome, obviously very smart and a Jock… that qualifies for cocky, doesn’t it?” He said he hadn’t quite heard that definition before, but didn’t remotely seem bothered by it. I heard later he repeated the interchange with nurses… in a nice way, not mad or anything. I really can’t believe I told a surgeon he was cocky. I should embrace it; I may never get another chance to say such a real-true thing. 

All this time, my client was having pretty frequent contractions. We’d get quiet during them and then more animated afterwards. She was an active participant in the conversation, so it was a sweet time. 

So, Mr. Cocky (in a good way) wanted to do a vag exam and rupture mom’s membranes; she had no problem with this. (Remember, this wasn’t a typical doula client who didn’t want interventions. This mom didn’t mind “interventions,” but just needed to know when things were coming. Interventions are in the eye of the beholder?) 

The exam, about 30 minutes after we got in the room, showed mom to be six centimeters now. Dang, she was clicking along! 

And no epidural. And no moaning. No rocking. No real indication that she was having a contraction beyond her focus on the ceiling and the waves on the monitor. Later I learned mom was counting the vent slats in the vent on the ceiling. Over and over again. She told me this was her distraction, her way to focus on the contraction without getting swallowed up in it. I thought this was a rather interesting focal point and wondered how many women did the same thing… or, conversely, how many women could do this and have it be a very effective way to work through the contractions. 

I watched, mesmerized by her labor technique. 

After the doctor left the room and things quieted down, the nurse handed me the paperwork so I would be able to pick the right times to ask the questions and have her sign. I immediately set aside the one about kids visiting and her menu; those could be filled out later. I then had her sign the others, before even filling them out. I already knew her wishes and they didn’t include changing any of the consents. When she was inbetween contractions, I’d quietly ask the questions and stop as I saw a surge starting on the monitor. Again, it really was a challenge to know when she was having a contraction or not because she was so peaceful no matter where she was in the pattern. Here, the monitor was very helpful. 

A nurse came in to set up the birth cart and I had to ask her to please slow down and quiet down. She looked at me weird, but I didn’t care; she slowed down. 

Then there was the ice. 

I’d offered sips of water every couple of contractions, but she shook her head no each time. When she asked her husband to hand her the ice, I was glad of it. But I watched this mom do something I’d never seen before. As the contraction built, she put more and more ice in her mouth, chewing to an unheard rhythm she herself felt. Chomp. Chomp. Chomp. It was amazing! Still no moaning or rocking. Just dumping more and more ice in her mouth as the contraction built and all we could hear in the room was crunching ice. Really loud. When I told her later that women who have ice in their mouths at that late stage usually spit it out when a contraction comes. She thought that was odd, telling me she was counting the ice as she crunched it into oblivion. Laughingly, she also told me that spitting it out would have been a waste of great ice. And seriously, who doesn’t love hospital ice? She was running low, so I stepped out to grab some more, but by the time I got back, she no longer wanted it; it wasn’t distracting enough anymore. 

It was only now that she began making noise. Nothing loud or like moaning, simply a squeaky sort of song. Oh, yes… labor was picking up steam. I was so impressed by her body’s pouring oxytocin into her system, the contractions now less than two minutes apart. When I got back with the unwanted ice, the nurses were watching her monitor screen and one asked, “Is she pushing?” I chuckled, thinking, “Duh.” The nurse came in and checked her. “8,” she said. “Don’t push or your cervix will swell.” I’m sure I rolled my eyes and told mom she was doing great listening to her body. The nurse left for a moment and when she came back in, she brought a tornado of activity. 

I asked everyone to please slow down. One nurse clomped over and hit the button to lower the head of the bed… a jarring experience for mom. I asked her to stop, please; she did. Then she pulled the leg braces/stirrups out and grabbed my client’s leg and started to put it in the stirrup. If I hadn’t had to remain calm, I think my head would have spun off. “STOP!” I whispered-yelled. “Put her leg down. Gently.” She looked at me like I was possessed and I left my client’s side to walk behind the nurse and hissed, “She has epilepsy.” That was all she needed to hear. Why she wasn’t briefed is beyond me. Every single person who walked in that room should have known. 

So, I asked my client if I could lift her legs into the braces and she nodded yes. I gently moved her legs into place and the doctor came in, gowning and I heard the nurse say, “She has an anterior lip.” What the hell?!? She’d just said she was 8! She lied and for crying out loud, she didn’t need to. The doctor did a vaginal exam and lifted the lip up in less than a second and with the next contraction, the head was on the perineum. 

The leg nurse whisked by and dumped a bottle of cold Hibiclens on my mama’s perineum. My poor client! I couldn’t put my hand out fast enough to stop her. I looked in my client’s shocked eyes as she tried to tell them she’s sensitive to soaps. And perhaps they might not want to shock her. And maybe, just maybe, they could have said something to her, like, “Is it okay if I pour a little soap on your bottom?” (Can you tell I’m more than a tad frustrated with the woman-as-object belief system?) I let her know we’d wash her very well after the birth. (Are doctor’s really taught to clean the perineum still? What a dumb belief, that the perineum needs to be cleaned. Only a man could think a perineum is “dirty” enough to be cleaned for a vaginal birth. Sheesh.) 

Now it was time to push. Now that the stage was set for everyone else. Never mind she’d been pushing for a few minutes already. And the head had come down fantastically without any coaching whatsoever. No, now she needed direction and education. Really? Let the cheerleading begin. 

When I talked to my client afterwards, she said she was only focused on the doctor, her husband and me, so she was protected from the chaotic yelling at her to push. The woman had a ten minute second stage. And it took three minutes for the baby to be born from the time we first saw her head. Yet, every nurse there, as well as the doctor kept trying to tell her how to push. I’m serious. 

“Take a deep breath. Let it out. Take a deep breath. And push, counting to ten.” 

Are you kidding me? The woman coughs and a quarter of the head gooshes out! 

“No, not like that. You’re wasting your energy.” 

 I couldn’t believe the surreality of the situation; it was so absurd I really could barely accept they were instructing her this way. I kept whispering to her, “You’re doing great. Exactly like that. Yes… you’re doing great.” She told me that’s all she heard. Thank goodness the cacophony of shrieking nurses remained in the background of this mama’s perception. 

(When I was telling Sarah about this part, she looked at me stone cold serious and asked, “Are you sure you’re going to be able to do this?” My daughter said the same thing. Uh, yes. I can do this. I might have to write about it a lot, but I can certainly do it. There are ways to limit/stop this really odd ritual.) 

The baby was quickly born and it was as if she came with a magic wand that made everyone shut up. The placenta was born and mom sutured and magically, everyone but the nurse and doctor disappeared. It was calm and quiet in the room again. Finally. 

I’ve looked at that noisy part and talked about it with my client and she said she was so far inside by then, the noise wasn’t as high a risk as a trigger. Had that happened earlier in the labor, she absolutely could have had a seizure. But through her own coping skills, she learned to go deep inside, creating an effective barrier from the institutional chaos. I apologized for not being able to get them all to shut up, but she said it was my whispering to her that she was able to hear. At first she was thinking, “Go away!” before realizing what I was doing; joining her in her inner space, letting her know she didn’t need to listen “outside,” that her “inside” had all the right answers. I’m just really glad I was able to help. 

A beautiful baby girl was born and within a few hours, mom began nursing the baby. But, she quickly realized the daughter she’d known on the inside was not the same baby she had on the outside. It seemed her baby was getting much more of the medication via breastmilk than through the placenta. Lethargic and losing weight, mom decided to wean her baby off breastmilk and now that she’s on formula, she’s totally waking up and acting like the baby mom knew inside. (And yes, she’s aware of donated breastmilk.) 

Overall, mom (and dad) were really pleased with the birth experience. Her success was ultimately measured by the fact that she had no seizures during the birth at all. Postpartum, she received a private room and didn’t have the parade of strangers most patients have, the strict rules obviously noted somewhere everyone could see. 

If I could do anything differently, I would have made a sign to put on the door. I don’t know why I didn’t think of it earlier, but the experience taught me a valuable lesson for the next time a woman has needs beyond the basic human rights needs. Hmmm… maybe a sign on every door isn’t such a bad idea. Do any of you do that with your clients? Maybe a sign on the door can replace a birth plan? Hmmm… not a bad idea. I’ll have to thank my mama for the idea. 

I know I’ll be thanking her for a long time for allowing me into her space for this precious birth. A new experience, it was something I would happily (and respectfully) repeat with others. 

Let peace and quiet prevail.