No Birth Plan Ever Survives Contact with the Enemy

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 and 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.

This head back, eyes-closed repose is not from blissful relaxation. It is because I literally could not hold up my head after six hours of hunching and pushing.

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.

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Danielle LaSusa Ph.D. is a Philosophical Coach and Consultant. She helps new moms grapple with what it means to make a person. She is the co-creater and co-host of Think Hard podcast, which brings fun, accessible, philosophical thinking to the real world.

The Wisdom of the Fire, or Why Philosophy Won’t Make You Happy

  Philosophy, the “love of wisdom,” can help us to live better, happier, and more fulfilling lives. As someone with a Ph.D. in philosophy, who has been reading and teaching philosophical texts on better living for over a decade, I have always wholeheartedly believed this claim—that is, until I went on a ten-day silent meditation retreat.

Before the retreat, I was convinced that deep, intellectual reflection and critical thinking about the aims and goals of life could lead me to a richly satisfying and genuinely happy existence—you know, that bit about the unexamined life. And, indeed, the lessons I’ve learned in the classroom have made a more thoughtful person, with a more coherent worldview, and a clearer story I can tell about who I am.

But, in the inevitable moments of depression or desperation that we all face, I found little solace in my books and intellectual commitments. Philosophy failed, even in traditions that are all about developing happiness, such as Buddhism, which teaches that minimizing desire will bring peace and contentment. For all of this reading and reflecting, I found that learning that I ought to want less didn’t make me feel any less desire. It just made me feel like a selfish, indulgent person, who should go look at more “life edit” blogs. In short, philosophy made me feel smart, but it didn’t make me feel happy.

After years of feeling dissatisfied and mildly depressed, I signed up for a 10-day retreat to study Vipassana meditation, (which means “to see reality as it is”). According to the course’s teacher, S. N. Goenka, Vipassana is the same technique that the Buddha himself used to become enlightened.

I was surprised to learn that students of this meditation course are asked to leave all reading and writing materials at home. What? No journal? How was I supposed to reflect, process, and work through my spiritual awakening? How would I remember what I’d learned? If not sitting contemplatively in the forest and writing, what would I be doing all day?

Turns out, I would be doing a lot of sitting—sitting very still. The strict schedule at the meditation center required that all students gather in the meditation hall for one-hour-long sessions of sitting quietly, three times a day. This may sound about as interesting as reading Hegel, but the kicker is that during these one-hour sessions, students are also asked to make a strong determination not to change postures. Don’t shift, don’t stretch, don’t move. “Don’t open your eyes, your hands, or your legs.”

Oh.

The technique takes as its foundation the awareness of the body’s sensations—without reacting to them. Sitting silently, bringing my attention through every part of my body from head to feet, without shifting around in my seat was, at times as tedious as it sounds, but more often, it felt like sitting on a bed of hot coals. When a twinge in my hip slowly built to a pulsing pain, and then a searing, screaming fire, it awakened all my of mind’s habitual desires to escape, to adjust, to fix it so that the pain goes away. It put to the test my ability to, as Goenka says, accept reality as it is, and not as I would like it to be.

Now this was learning to diminish desire. Put myself in a situation in which I want something, (i.e that burning in my muscles to go away), really, really badly, and very immediately, and just sit in the center of the fire.

I had to tell myself over and over that is was just pain, that I was not going to die, (although one time I did actually feel like I might), and to keep, as calmly as I could, bringing my attention slowly from head to foot and back again. I discovered that, when the mind stops resisting the pain, eventually the body relaxes, and the pain subsides.

Through this experience, I learned much more than I ever could have in reading a book about meditation. For one, I learned that I am capable of enduring much more than I thought. I sat with excruciatingly severe pain, not moving, and trying to talk myself into staying composed as sweat beaded on my forehead. Granted, several times after a particularly hard session, I ran to my room and sobbed for 30 minutes, but I also felt like I had let something go—an old pain that I’d been carrying around for a long time.

I saw a glimpse of the same thing I had read in those books—that indeed, all things are temporary, even if it feels like a pain that will last forever and swallow you whole.

I learned too, that when I stopped reacting so much and could be equanimous with the sensations of my pain and pleasure, (well, not so much pleasure and just relief when the pain subsided) my capability to see and observe things increased.

I’d read plenty of philosophical texts about how we acquire knowledge, but I had never experienced a lesson in perception like this before. After a week of meditating, I literally noticed things I hadn’t days earlier—I would go out walking on the same forest footpath and hear moles rustling under the leaves, see tufts of tiny mushrooms, smell the musk of wet moss. As my reactivity and my obsession with my own thoughts decreased, my senses heightened.

I learned to be more present, more mindful, more focused, and I started to feel moments of, dare I say, deep peace and contentment.

I learned that knowing something from reading or hearing about it is one thing and knowing it through experience is entirely different—one is intellect, the other is wisdom. And there are certain things that the intellect alone can never know. For someone who has never smelled cinnamon, reading about it will only leave a confused and vague impression. Indeed, reading the Dhamma Sutra or latest issue of Yoga Journal, or spending a dozen years buried in books only got me so far.

I had to go sit in the fire.

The Politics of Bathroom Changing Tables

When my daughter was about a month old, my husband and I took her to a restaurant for the first time. We were very proud of ourselves for making it out of the house and into the world with an infant. When you’re a new parent, the world looks different than it did before.

My husband and I are what you might consider a “modern couple.” We share in the parenting duties, at least as much uneven family leave will allow. He had to return to work two weeks after our daughter was born, leaving me home alone with her most of the day. But, when he’s home, in the evenings and weekends, he’s often is the one to change her diaper, figuring it’s the least he can do, given that I breastfeed her every two hours and haven’t had an uninterrupted night of sleep since she was born.

So, when we arrived at the restaurant, a kitschy independent barbecue joint, and knew she needed a diaper change — as evidenced by the concentrated grunting and telltale sounds of a diaper being filled — my husband grabbed her and headed to the bathroom.

I was relieved to have a few precious moments alone. I took off my sweater feeling sweaty and overheated. I wasn’t sure if it was because of the cashmere I was wearing or my fluctuating postpartum hormones. I downed the glass of ice water at the table, perpetually thirsty from constant breastfeeding, and picked up the menu to see what kind of barbecue would satisfy my iron-deficiency cravings.

But, before I could even scan past the appetizers, he returned saying that the men’s room didn’t have a changing table. He shrugged with a sorry look and handed the baby to me. “You want to see if the women’s room has one?” I sighed and scooted my right way out of the booth, slung the diaper bag over my shoulder, and headed to the ladies’ room. There was the changing table.

Before I had a kid, I barely even noticed things like changing tables. I know now that most public women’s rooms have one. But, many men’s don’t. When we’re out together in public, I’ve started changing our daughter just as a default, because we’ve had enough thwarted attempts for my husband to do it. I’ve now started to ask him when he returns from a public men’s bathroom if there was a changing table inside.

That’s is the thing about experience. New experiences inform you about some aspect of the world that you were blind to before. And you often don’t pay attention to the politics of how this world around you is constructed until you need to engage with it in a certain way. The fact that I now have been tasked with public diaper changing means that I really pay attention to where changing tables are located. 

And this is an aspect of the world that is, frankly, sexist. It both reflects and perpetuates the dominant care-taking gender roles: women change diapers, men don’t. My husband couldn’t change a dirty diaper in that restaurant even if he wanted to, unless he went into the women’s room or changed our daughter’s poop-filled diaper on the dining table.

I’ve started to think that second option would be the appropriate move. If the restaurant staff or any of the other patrons complained about the smell, we would have to kindly explain that my husband is the one who changes the diapers, but that this restaurant didn’t provide a changing table in the men’s room. 

Maybe by saying these things out loud, rather than enduring them quietly, by calling attention to a structural failing in the way our world is organized to those folks who don’t usually pay attention, we can start to change more than just dirty diapers.

The world is better because this poem by e.e. cummings exists

  i thank You God for most this amazing

day: for the leaping greenly spirits of trees and a blue true dream of sky; and for everything which is natural which is infinite which is yes

(i who have died am alive again today, and this is the sun’s birthday; this is the birth day of life and of love and wings: and of the gay great happening illimitably earth)

how should tasting touching hearing seeing breathing any–lifted from the no of all nothing–human merely being doubt unimaginable You?

(now the ears of my ears awake and now the eyes of my eyes are opened)

e.e. cummings