No Birth Plan Ever Survives Contact with the Enemy

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  As soon as I learned what an episiotomy was, I knew I didn't want one. For the uninitiated, an episiotomy is a procedure done to help make room for a baby during delivery, by making an incision in the perineum, the tissue between the vagina and the anus. Yeah, that's why I didn't want one. In fact, when I filled out the intake form on my childbirth class, I wrote it down as one of my biggest fears. But, in the immortal words of Mick Jagger, you can’t always get what you want.

My "birth plan" was to do an unmedicated, all natural birth, with as few interventions as possible. I wanted to experience the surge of hormones, to prove that I had the grit, to commune with my maternal ancestors who I imagined were screaming and squatting in fields and log cabins.  I talked with friends who had done it au natural, who said that the experience made them feel strong and powerful, and who told me to be aware of the "ring of fire", (the bit when the dreaded episiotomy might happen). My husband and I had taken all the birthing classes, and my cousin who is a naturopathic doctor agreed to be a birth companion, to serve as a kind of doula, providing massage and acupuncture during labor.

But, as they say, no battle plan ever survives contact with the enemy.  In the end, I had a labor and delivery that involved almost every kind of intervention, save a cesarean section, and I was one contraction away from being wheeled to the OR. All this, in spite of delivering Portland, Oregon, one of the most progressive birth friendly places in the country, where standard labor, delivery, and postpartum practices aim to return to the “wisdom of the body,” rather than to operate at the convenience of the doctors or to clear out hospital beds as quickly as possible.

I delivered at Providence Portland Medical Center which is in the process of being certified as a prestigious “baby friendly” hospital by the Baby Friendly Hospital Initiative, (a program launched by the World Health Organization and UNICEF to recognize hospitals and birthing centers that offer the optimal care and support in mother/baby bonding and breastfeeding).  My doctor was general practitioner recommended by a friend, who told me in our first appointment that she tends to take a non-interventionist approach whenever safely possible. Plus, she said that in her ten years of delivering babies, she had only ever done two episiotomies.

And yet, for all the preparations and precautions, the earnest faith in my body and my own iron will, the perineal massage, (ya know, to try and stretch things out down there as much as possible ahead of time), things did not go according to plan.

My water broke at the very beginning of labor, at 2:30 in the morning, which in effect started a countdown clock. Medical practices aim to deliver a baby within twenty-four hours of a women’s broken water because that sack of amniotic fluid that serves as a barrier to bacteria; every hour that passes before delivery increases the risk of infection to both mother and baby. So when my husband, my cousin, and I checked into the hospital with fast and furious contractions, I was admitted, despite the fact that I was only two centimeters dilated rather than the five that is typically accepted.

But, for whatever reason, once we made it to the labor room, my body slowed way down, with contractions now only every fifteen to twenty minutes, despite my best efforts to get labor moving by walking the halls, hot showers, and even a little Michael Jackson dance party, inspired by that viral video of the woman doing the Tootsie Roll during her labor. By 4:00 pm, though, my doctor said that we had to get things progressing, so she ordered that we start Pitocin, a synthetic version of oxytocin, the hormone that signals the uterus to contract. So much for my unmedicated labor.

But, it worked. They put me on a very low dose of Pitocin and, as they slowly increased it over the next few hours, so did the contractions. Although I could no longer walk around without being attached to a machine, I was still standing, rocking, sitting on a birthing ball, as my husband and cousin took turns rubbing my back and holding my hands, and by 6:30 pm, I was six centimeters dilated. Only four more to go until the fully dilated ten centimeters. At 8:00 pm they checked me again when attaching an internal fetal monitor—because the external one I was wearing around my belly kept slipping off—and I was eight centimeters. My doctor said that it should only be a matter of time and to let the nurses know when I felt a strong desire to push.

So, I kept standing, rocking, moaning, and breathing through the most intense pain of my life. At hour twenty-two of active labor, my legs were starting to quiver from exhaustion, and I was beginning to wonder how I would make it through transition and pushing when I could barely stand. At midnight, my doctor returned and checked my cervix again with the heartbreaking news that I was still only eight centimeters dilated.

In my birth plan, I stated that I didn’t want to be offered pain medication. If I wanted it, I would ask for it, so I wouldn’t feel pressured into taking something I didn’t really want. But once my doctor told me that this stage of labor should take around two, maybe three hours, rather than the four I had already endured, and that we’d have to increase the Pitocin, I saw in her eyes that something had to be done. I knew I wouldn’t have enough energy to push when it came time. I agreed to an epidural.

A few excruciating minutes later, the Magical Epidural Man entered the room, and performed some miraculous, wonderful wizardry on my spine. I immediately felt the lower half of my body go numb and, no exaggeration, a minute later, I was asleep. Two hours after that, my doctor and nurses came into the room and told me that I had fully dilated and it was time to push. Sometimes the body just needs to relax, my doctor said. I was very grateful for modern medicine, in that moment.

We were getting close now. In theory, pushing is the big finale. So I pushed. And pushed. And pushed. This stage of labor typically takes any where between five minutes and two hours, but after two hours had passed, and the baby was still not coming down, my doctor asked for an OB, who determined that she was posterior facing, with the back of her skull against the back of my pelvis. She was backwards. He needed to reach in and corkscrew her 180 degrees. After another hour of pushing and rotating, my face now covered in an oxygen mask, he was only able to get her halfway there. He started talking to me about options: forceps… vacuum…cesarean... “I really don’t want a c-section,” I pleaded. “I’ll push for as long as it takes.”

After some raised eyebrows and glances exchanged between the doctors and nurses, he turned me on my side and let me rest for half and hour in the hopes that gravity would do the rest. It worked. My baby was now facing the right direction, but after another forty-five minutes of pushing, she still had not come down.

Now, twenty-nine hours after my labor began, it was time for the morning shift change at the hospital. Another OB and nurse came in, and after assessing the situation, she determined that a vacuum assist was needed. This is essentially a little suction cup that gets attached to the baby’s head to help pull her out. Intervention number, what are we up to now? Pitocin, epidural, fetal monitor, manual rotation, vacuum…

The new OB warned me: you only get a few tugs with the vacuum, three or four contractions worth, and if it the baby is not out by then, we’d have to go to the OR for a c-section. Going on hour six of pushing, I craned my neck and bore down with all the strength I could muster. I started to run a fever.

Finally, the OB said, “You’re almost there! Reach down an feel your baby’s head.” I reached between my legs and my fingers grazed the warm, round mass. I started to cry. “Just a few more pushes!”

And then, slick and quivering, she burst into the world.

I didn’t know it at the time, thanks to the epidural, but with that last push the OB deftly snipped my perineum to make room for my baby’s shoulder, which would not have fit otherwise. Yep, the cherry on top of the layered intervention cake: an episiotomy.

As difficult as the labor was for me, I think it was worse for my baby, who emerged with an elongated head, a big purple welt from the vacuum seal, and a raw patch of missing skin from the manual rotation. The pain she must have felt prevented her from breastfeeding well for the first several days. Every time I brought her to my body to feed, she screamed so much that her lips turned a dusky purple, and by then we were both in tears. We spent an extra night in the recovery room and then a night in the neonatal intensive care unit because my doctor was concerned about her dipping oxygen levels. We were visited by a few lactation specialists and the nurses helped us to try to get her to latch. In short, were both rather traumatized by the experience.

Childbirth is tough. There’s a reason that it is considered the punishment for Adam and Eve’s Biblical transgressions. In centuries past, my ancestors who screamed and squatted in fields and log cabins not only glowed in the bliss of maternal hormones, but also died prematurely of infection, eclampsia, blood loss, and obstructed labor, (which my labor would have certainly qualified as).

However, it is also the case that, in spite of the declining death rate of last 150 years, the childbirth mortality rate in the U.S. and Europe rose during the first half of the twentieth century. Although births had long been the purview of midwives, in the 1800s, undertrained and overeager male doctors started to participate in the increasingly lucrative business of labor and delivery. But almost immediately, childbirth mortality rates started to soar because, as this was before the theory of bacteria, these doctors had a habit of wandering directly from autopsies to deliveries without first washing their hands, and of overusing newfangled instruments and surgical practices.

Furthermore, as male doctors began to take over the birthing business, much of the knowledge of the midwives was lost. In her essay, "Coming to Understand: Orgasm and the Epistemology of Ignorance," philosopher Nancy Tuana points out that even though midwives and many doctors in other countries know how to turn a breech baby, for example, fear of malpractice litigation and business interests have directed medical practices in the U.S. toward c-sections. Over the last century and a half, the wisdom of midwives and the wisdom of women’s bodies in the act of delivery has been undervalued and thereby lost—or rather, rendered silent—and replaced with medical interventions in a male dominated medical industry. Tuana calls this lack of knowledge about women’s health and bodies a manifestation of the “epistemology of ignorance.” Knowledge like this is not simply passively lost, but instead, “ignorance is frequently constructed and actively preserved, and is linked to issues of cognitive authority, doubt, trust, silencing, and uncertainty.”

There is a moment during my labor that I keep coming back to. During my six-hour stretch of pushing, I was lying flat on my back, feet in the stirrups, chin to my chest. This seemed to me like a very unnatural way to birth a baby, and definitely not the birthing position I had envisioned for myself. At about hour two, I suggested that I get on my hands and knees, the way I had hoped to deliver, and a posture that would allow gravity to help the process. But I was told that because my lower half was numb due to the epidural, I had to stay on my back. I remembered the teacher of our birthing class saying that even with an epidural, it was possible to get on hands and knees if you moved slowly and had lots of support, but my doctor seemed so firm in saying no, and I was so exhausted, that I didn’t argue.

I wonder what would have happened if my husband, my cousin, or I had insisted. I wonder what would have happened if my doctor had trusted my instincts more. I heard afterward, (from another female doctor I struck up a conversation with at a restaurant, who had delivered over 700 babies), that when babies are turned the wrong direction, getting a woman on hands and knees usually gets them turned around. What if I could have avoided the manual rotation, the open sore on my baby’s head, the vacuum-incurred bruise, the weeks of breastfeeding difficulty, and the whiplash in my neck, just by a simple change in position that I had a gut feeling that we should do? Would a midwife have listened and trusted me more than my doctor did? Would having a certified doula in the room to advocate for me have allowed me to change position?

Since I became a mother, I’ve come learn that a mother’s intuition is a real thing. I seem to know when my baby is too hot or too cold, gassy or hungry, sick or sleepy, even though she can’t directly tell me these things. My breasts tingle minutes before she wakes up from a nap and wants to feed. There is a strange Spidey sense to the whole thing. It only makes sense, given that she grew and lived inside of me for the better part of a year. Why would we not think that this intuitive knowledge would begin during her labor, or even before? Why do we not trust a mother’s intuition during the birth of her baby?

Ending up with a labor and delivery so unlike the one I wanted meant that I had to grieve the loss of what I had hoped for. Not only that, but I had to somehow process and work through the trauma of all those interventions and the injury to both my daughter and me, while in the hormone surging, sleep deprived, foggy weeks of new motherhood. In the end, I’m not sure if I should feel angry at the modern medical establishment for failing to value to the instincts and voices of women in labor—and thereby maybe unnecessarily causing avoidable injury to my baby and me—or grateful to it for providing the epidural that was able to move my labor along and possibly saved us from infection or even death. I have talked to so many women who have similar stories, and who don’t know how to feel about it.

Luckily, we do seem to be moving in the right direction as a country. More and more hospitals are trying to move away from interventions and starting to see mothers and their instincts as legitimate and valuable sources of knowledge during the labor process. In spite of the fact that I endured a lot of unwanted interventions, the doctors and nurses, (all of whom were female except the one OB and Magical Epidural Man) communicated with me clearly, deferred to me when possible, (except for that one moment during pushing), and included me as an active participant in my own labor. My mother, who had a similar labor with me in the early 1980s, was given morphine without her knowledge or consent; my father was asked to sign off on it. And today’s practices are a vast improvement over those of the 1950s, when women checked into the hospitals, were essentially knocked unconscious, and then woke up with a swaddled baby in their arms.

But, unfortunately, I think my positive experience is the exception, rather than the norm, and is thanks to all of the work and research I did in trying to find the most baby friendly medical establishment I could. I’ve talked to many other women who say they felt pushed around and as though they totally lacked agency during their labors. In many parts of the country, a woman in labor is treated as a passive patient rather then a person with inherent wisdom. We still have a way to go in improving medical labor practices, and it requires trusting and valuing women’s intuitive knowledge of themselves and their bodies.

It turns out that the episiotomy wasn’t nearly as bad as I had feared. Because of the epidural, I didn’t even feel it happen, and my wound was stitched up and healed cleanly and quickly. And in the end, I have the most gorgeous baby girl who has brought incredible joy into my life. And, although I knew labor would be intense, I never really believed beyond the most remote possibility that she or I wouldn’t make it out alive. For that, I am grateful. But I hope that, if my daughter chooses to have children a few decades from now and her birth doesn’t go according to plan, she will never have to wonder whether or not it was because her doctor values her wisdom.