I had a brief foray into the world of blogging a couple years ago and subsequently abandoned ship.

Well a couple weeks ago I was in NYC and had the good fortune to sit down in conversation with the inimitable Betty Dodson and her cohort Carlin Ross. We recorded an audio podcast of one of our conversations.

I am delighted to share the link to that podcast here on my blog.

http://dodsonandross.com/podcast/2011/06/reclaiming-birth-our-interview-doula-jessica-kramer

I'll be contributing blog posts to their site DodsonandRoss.com and sharing them here as well thus reviving my participation in the world of blogging.

How little we know

I attended my first birth about 13 years ago. The care providers seemed like they knew what was going on. About three years later I became a doula. After doing some workshops and attending a couple births I thought I knew what was going on. Somewhere in those first couple years I started to feel like every birth I attended I knew a little less. Ten years later that sometimes still feels true.
Thus far the birth lesson (or un-lesson) of 2009 seems to be about what "active labor" looks like, how it's defined and what helps it progess. In the birth world we often discuss when a woman "gets active". To our minds we are classifying the part of labor that shows consistent progression and a certain intensity.
I attended a very beautiful birth yesterday. A mother giving birth to her 3rd baby. Upon arrival, she seemed like she might be in active labor. When the midwife checked her she was 2cms dilated and 50% effaced with the baby still very high up. Medically speaking she was certainly not in active labor. More subtly speaking it was sort of on the fence whether or not this was active labor.
And so we waited. We waited for a shift of some kind to take place. I usually suggest at this point that a woman either get some good sleep between contractions OR get up and move around to get things moving. This mother didn't really do either. She lay in bed not sleeping. At some point she did get up to walk around a little bit. Her contractions never got closer than 6-7 minutes apart. Technically speaking, contractions 6-7 minutes apart don't open a cervix up to fully dilated and don't move a baby out. My mind did wander to the question of how long this would go on for? Was I going to be here for 5 more hours or 2 more days? I had to set this thought out of my mind because my job is to be there with her in her process at her pace. And so I was. After a few hours the midwife checked her again and she was a very stretchy 5cms dilated and 100% effaced. So it was hard to argue what she was doing or the progress of her labor. Her labor had not changed externally in its pattern or its subtle quality. She was coping no differently, the contractions were not closer together or more intense, she was not doing anything different, and she didn't seem any farther off in "labor land".
At some point she decided to get in the tub. Usually we say a woman shouldn't get in the tub until her labor is really active because it will slow labor down. But she got in the tub and nothing changed. After being the tub for a little while her water broke. The midwife asked her if she felt like pushing. She said no. The next contraction came and she pushed spontaneously. The contraction after that the baby crowned, his head came out and his body came out.
Her contractions still never came closer than 6-7 minutes apart.
In the past I would have said, yes, well, it was her third baby so....
But the fact is, I've seen this several times this year. I've seen the "multips" (mothers who already have a baby) with this sort of labor pattern and I've seen the "primips" (first time mothers) with this sort of labor pattern.
In February a client of mine (a primip) was laboring and it appeared that labor was not progressing. She was coping extremely well and the contractions were still fairly spaced out. At some point there was a very subtle shift and I timed a few contractions. They were a little closer together - maybe 4 or 5-7 minutes apart. But that's still pretty irregular and not a sign that she is in a steady active labor pattern. She decided it was time for us to go to the hospital. Something in me thought, well, she's either going to be 2/3 cms dilated or she's going to be 8/9cms dilated. It's gonna be one or the other. We arrived, her doctor checked her and she was 9cms. The doctor was quite surprised and thought things must have stalled because this did not look like a woman 9cms dilated. Her labor never really changed pattern until she started spontaneously pushing when there was a slight shift in pattern.
So what does a woman need to do to make her labor progress? Only her body knows.
How far apart do her contractions need to be to fully open her cervix and move that baby down? Anything is possible.

I hesitate somewhat to write about this because I am frequently with first time moms in labor explaining that this is still early labor, not active labor; explaining that things will need to get more intense. Often they are asking if it's possible that contractions of this intensity and frequency could possibly last the whole way through, and the answer is no. Often they are saying "Well, maybe this IS active labor", and it's not. Often they wonder if it could continue at this same rate and suddenly the baby is coming out - the answer is almost always no, especially with a first time mom. The trap here can be a tightness around trying to keep the intensity of labor down, the wishful thinking that it won't become more intense and more frequent, the hope that labor need not rock you to the core.
My point in writing about this is not to let women know that it's possible for contractions to never get closer together than 6 minutes apart, nor to encourage women to leave for the hospital early because "what if it is farther along than we think". My point is that we as practitioners and care providers should be careful about our definitions. We should be careful to watch ourselves caught in the trap of thinking we know. Careful about telling women what is necessary for her baby to be born. Careful about getting caught in the trap of our own impatience and discomfort with the unknown. My point is that absolutely only the mother and her baby knows what is necessary and what needs to be done.
As a doula and midwife assistant my job is to look her in the eyes with warmth, to touch her with gentleness, to pass her a glass of water regularly, to check the baby's heartrate, and only when complications start to arise should we get more involved with instructing her and problem solving. And most importantly it is my job to remember how much I don't know and how utterly miraculous and mystifying the process of childbirth is.

What's the difference between homebirth and hospital birth?

Last night during an interview with potential clients the mother-to-be asked me what I see as the difference between a homebirth and a hospital birth. – A difficult and complex question to answer. I paused. And then I started with my best attempt at an answer.
A hospital birth is a finite medical event. A homebirth is a big experience that takes place in the midst of normal daily life with a few traces of medical paraphernalia.
During a hospital birth there is a moment when the couple arrives in the hospital and the medical records begin. People go to the hospital for medical care and this is where the orientation lies. Walking into a room full of equipment and the clients will negotiate themselves and their experience around this environment and equipment. They will meet some medical professionals they have never met before and some that they have. The nurses will be moving from one patient’s room to another, and if the doctor or midwife is there and becomes tired, he or she will go to another room in the hospital to sleep. The baby will be born, the placenta will be born, the doctor or midwife will leave, the baby will be weighed and measured (maybe in the same room as as the mother and the equipment brought in, maybe in the nursery), and they will be moved to a postpartum room. This may all happen in a great rush or it may happen more slowly but it’s a fairly set sequence of events in a somewhat fixed period of time. At the end they will leave the hospital to return to home, different than they entered.
A homebirth is less a finite event and more a broad experience. The home that the parents-to-be have built around their lives will transform somewhat to build itself around the experience; the birth attendants will similarly build themselves around the parents home environment and needs. The mother-to-be may wander in and out of her kitchen to get food and water, her bathroom to shower and brush her teeth, her bed to rest.... Small (ie. transportable) medical equipment will be set on a piano bench, a coffee table or a bedroom dresser. The midwife may become tired and lie down to sleep on the couch. The mom’s partner will probably be in and out of the kitchen to prepare food for him/herself and the mom. She may become cold and walk to her dresser to pull out a comfy socks. Maybe she becomes dehydrated at some point and lies in bed while her midwife gives her an IV which she then places on a hanger from the closet to hitch onto a nail in the wall or a shelf by the bed. The baby’s heart rate will be listened to on a regular basis but with a small doppler that disappears to the floor beside the couch (or the bed or the bath...). At some point the progress of labor will become intense enough that the focus will not travel far from the room the mom is in. Everyone may be in the same room, the piano bench with medical equipment moved closer but probably without much attention to it. After giving birth the process continues; the placenta in a bowl and carried to the sink for inspection, some quiet time alone while someone is in the kitchen cooking the new parents food and the midwife is at the dining room table taking notes. At some point maybe the new mother showers while her partner holds the baby, and the bed is freshly made. At some point when the parents are ready the baby will be weighed and measured on the bed while the parents lie in bed resting and watching. And eventually when things have settled enough, slowly people will leave so you can all sleep.

I’ve been hearing lately about a book called Homebirth In The Hospital and I’ve had many people say, “I want to have a homebirth experience in the hospital”. My response to both of these is the same; it is absolutely possible to have a beautiful natural birth in the hospital, but the experience will not be like a homebirth because you are not at home. You are not in the environment that you have built around your life and the environment on that day is not building itself around you. A hospital birth entails you leaving for the hospital and creating your experience within an environment created for medical purposes. If what you want a homebirth experience, the hospital is not the place to have that and if what you want is a hospital environment, home is not the place to have that.

I am writing about this because there seems to be such polarization between natural birth and medical birth, between homebirth and hospital birth. These are not mutually exclusive and neither one is right or wrong. It is really about what the individuals want and where the individuals (or couple, or family) feel most safe and comfortable. A home and a hospital, they are really different kinds of places.

So this is what I’m thinking about at the moment. I’m not sure I’m done thinking about it.