Sunday, October 25, 2015

When Georgia Got Here

for Georgia, with love

A week ago right now: I was about to finally climb in the birth pool. Doubting the stamina of our building’s water heater, I had inadvertently filled the pool with water about 20 degrees too hot, and it was taking forever (and lots of bowls of cold water that your dad was shlepping) to cool it back down to the point where it wouldn’t cook either of us when I got in. But let me back up and tell you the rest of your story.

The night before, I had woken up to pee and noted a contraction that was a little more serious than the usual Braxton Hicks brought on by such a change in my position. Pregnancy insomnia had inspired my rule that I wasn’t allowed to check the time when I woke up in the night, but after I got back in bed and lay awake for a few more contractions, I decided to break it: 3:38am. A few more and I decided it was official enough to open up the contraction timer app on my phone, the same one I had used with Frances’s birth. (“Time since last contraction: 873 days”). To my wee-hours dismay, this app now featured a “Sponsored by [formula brand]” icon, so I downloaded a new one and got on with the self-quantifying.

Contractions were irregular, anywhere from 6-15 minutes apart, and stayed pretty irregular throughout the next few hours into the dawn. I coped by sort of rolling around in bed and snoozed to the extent I could. I checked Aaron’s phone, between our pillows, and thought about whether I should turn his 5:45am alarm off so he wouldn’t get up for work, but instead sleep in, in preparation for the labor ahead. I also took a minute to let myself believe that labor might really be happening and a baby might really result. The psychological gulf between pregnant and baby is so large.

I left Aaron’s alarm on and he left me and Frances in bed to keep snoozing. She woke up around 7 as usual and came over to nurse, our morning tradition for the last many months, lingering, snuggled up together in bed as long as possible. The several mornings prior, I had felt very sentimental about this time together, trying to treasure it, realizing it would disappear overnight one of these days. Good thing I took the chance when I did, because on this morning, her nursing cranked my contractions up to every 4 minutes apart, so we nursed briefly and then got out of bed.

We had a visit scheduled for 9 with Michelle, my midwife, so around 8 I texted her to describe my contractions and we chatted before she headed over. The mood was excited when she and her apprentice Orna arrived, with the official pronouncement that she wouldn’t be categorizing this visit as a prenatal check.

After the visit, we hung around the house for a while, tying up some loose ends and enjoying the specialness of knowing I was in labor, then decided to get outside for a family walk before Frances’s naptime. I put on a particular maternity shirt and asked Aaron to bring the camera, as I wanted some deliberate shots of my full-term belly before it was too late. We walked to Andronico’s and Frances and I got ham and cheese croissants, then a few blocks further for Aaron to get a deli sandwich at Irving Subs. Slowing or pausing when I had a contraction, Aaron and I enjoyed the thought that maybe we see pregnant people out walking in the middle of labor all the time - you wouldn’t know unless you happened to be looking while they lean against a pole and purse their lips for a minute.

Home after an impromptu photo shoot on the first vaguely attractive stoop we could find, Aaron tucked Frances in for her nap. I ate an apple with nut butter and took a long nap myself, waking every 20 minutes or so with a contraction.

Once Frances was up, I tried to get on with the day’s other project at long last - hanging up the last dozen pictures on the gallery wall that I had been trying to get to for months. Not only did I want some particular pictures up by the time I was laboring (pictures I am very fond of and had up during Frances’s labor), I knew that it was now or never.

The afternoon wore on, Aaron and Frances and I all puttering around the house, playing together or reading books here and there. Aaron took care of things and eventually cooked some soup for dinner with Frances’s help, and I tried my darndest to nail a painting to the wall whenever I could. Frances was the absolute sweetest, tiniest doula, completely responsive and thoughtful when I would tell her I had to take a break and do my contraction, sometimes holding my hand through it when I asked or patting and rubbing me a little on my shoulder or back. I was so glad for the many times I’d told her her own birth story and her familiarity with what labor would be like.

By this time contractions were pretty serious - definitely to the point that I had to stop what I was doing and find some way of coping, and moving quickly toward me being unable to talk through them. I was determined to do what I could during labor to help baby move around to good anterior positions, so coping was a lot of hands and knees, rocking my hips back and forth, walking, and leaning over the birth ball. I also found relief in singing or humming along to whatever was playing from my ‘Downbeat Birth’ playlist at the time.

At some point I started having nausea with each contraction and eventually vomited. I was having a hard time drinking or eating very much and worried about getting dehydrated and losing my energy. Furthermore, despite the difficulty of the contractions, they were still very irregular in interval and length, and I felt like I’d been at it for 12 hours with no progress. I was discouraged in part because it was just hard, and in part because I worried that the pattern indicated a posterior baby, one of the factors that made my labor with Frances so long and difficult. Long would be ok, but a long time at the intensity I was already experiencing felt overwhelming.

I finished nailing the last pictures up shortly before bedtime.

At bedtime, I felt very tender toward Frances and snapped a few pictures - a selfie of us and one of her with Aaron right before she went to sleep. I hoped I wouldn’t see her again until she had a sibling, and I thought about what a big change it would be to our relationship. I absolutely love both of these pictures and am so glad I took them:

Mama's baby

Dada's Baby

I expected labor would pick up and start getting serious after Frances went to sleep, so we set about filling the birth pool - as above, with water that could boil a lobster. I didn’t think to toss the thermometer in until it was nearly full! We opened the sliding glass doors and waited and checked it for a while, then Aaron finally gave in and started toting buckets and bowls of water back and forth from the pool to the bathroom. Finally, around 10pm, I got in the pool, and as expected, it felt amazing.

Unexpectedly, though, my labor slowed rather than speeding up as I had hoped. I tried to take advantage and snooze a bit, as did Aaron, but it wasn’t really possible in the tub, especially as I was determined to be belly-down or on my left side.  Assuming that with Frances’s bedtime my labor would speed up had also been a mistake, as I ended up feeling disappointed and frustrated again, similar to my discouragement from earlier in the day. I coped through difficult contractions with hip movement and little pep talks, either from me or Aaron, including this important reminder: the contractions are the thing I DO want. I also barfed some more, which was really not great for my enthusiasm.

Around 1am, Aaron suggested I could try getting out of the pool and walking around a bit. This sounded just awful, but I knew it was a good idea. I psyched myself up, made a route plan around the apartment, and had Aaron get my big plushy bathrobe ready. We walked and labored together for another half hour or so. I had a “what is going on why am I doing this I changed my mind” crying jag on Aaron’s shoulder.

For me, there are a few things that make labor pain bearable. It has a purpose - you know you get a baby at the end; it’s physiological - you know the pain is because your body is doing a good and healthy thing, not because something is wrong; and it’s predictable - you know it’s going to come and go with contractions, and get harder in a predictable way as you approach the end. It turns out that I need all three to cope very well, and hence I wasn’t.

We decided it was time to call Michelle and get some advice.

Michelle’s advice was to decide either to slow things down or speed things up, and her suggestion, it being the middle of the night and given my fatigue and state of mind, was to try slowing things down first. I got settled in the chaise longue with a bunch of pillows and managed to drift off; Aaron went and slept in the bed. I woke with occasional contractions but was able to breathe through them without moving significantly, meaning I could fall instantly back asleep as they ended. I had very distinct synesthetic experiences of these contractions - each one was a large rectangular field of white with a small blue square, like a mosaic tile, in the middle. I also dreamed Frances’s presence during them, as though she were standing next to the chaise and holding my hand.

After about two hours of this, I woke and went to sit on the toilet, where I continued to labor for another hour in a semi-wakeful state. I was timing contractions but otherwise tuning out as much as possible. It started to dawn on me over the next hour that my contractions were quite regular, and really rather close together, so after about an hour I decided it was time to rouse Aaron and call Michelle. Rousing Aaron: easier said than done. I was coping well on the toilet and really not in the mood to stand up if I didn’t have to. I tried texting him in the bedroom; I tried calling his cell. I sent about 25 texts in a row. I called three more times. No avail. I gave up and went in and jiggled his ankle, then called Michelle. I barfed again while we were talking, and she said she’d head over.

Waiting for Michelle, and then after her arrival, I labored leaning over the birth ball, coping by reading everything I could find on my phone and trying to breathe in a very measured way. I read back through about 4 days worth of facebook posts I’d already seen and cleared out every article in my feedly. Out of stuff to read, and assured by Michelle that it was now very unlikely to slow labor, I decided to get back in the pool.

Here we come to the part of the story where the universe decided to punk me a little bit. Whereas before it had been 20 degrees too hot, the water was now significantly too cold, and it was too late to climb back out. I felt murderous, but Aaron and Orna started another bowl and pot water brigade and got the temperature back up while I made my way through a few contractions - which fortunately, despite the unpleasant surprise, didn’t slow down. They were fast and very difficult to breathe through at this point, and I kept saying to Michelle, as though she were a birth fairy instead of a midwife, “I need a break, I need a break!” Each time a contraction ended, she would say, “Here’s the break,” and I would try to come back down.

At some point Michelle asked if I’d checked myself lately. I had been hesitant to, partly, I think, because I still had the mindset that this labor might go on forever and I didn’t want to be messing about introducing bacteria if I still had 3 days, and partly because the only other time I had checked during this labor, I couldn’t feel baby’s head at all and was pretty discouraged. But I gave it a shot, and here was the turning point of labor.

In Frances’s labor, by the time I was regularly checking myself and feeling her head, my water had broken and I was well into the hours of pushing it took to get her out. In other words, it was very clear what was baby head and what were my soft tissues. When I checked to see if I could feel this new baby’s noggin, what I didn’t take into account was that my water hadn’t broken yet. I could feel a wide expanse at my cervix, but it was soft, not hard like a skull. It took just a second, and then I exclaimed, “It’s the amniotic sac!” and realized in a rush that baby’s head was in fact very low, and very touchable, and that I might in fact be nearing the end.

Mind and body having realigned with each other, my water broke in the next few contractions, and I almost immediately started feeling the urge to push. Between grunts, I casually informed Michelle, who was sitting right in front of me next to the pool, that I was feeling pushy - very helpful information, I’m sure.

A few more contractions and the need to push ramped up dramatically. I gasped that I couldn’t move my hips back and forth any more. Michelle said I didn’t need to. I asked how I was supposed to relax my pelvic floor and push at the same time. Michelle said I didn’t need to relax it any more. She also said that if I wanted to give birth outside the pool, I would need to get out after the next 1-2 contractions. I had planned to be on dry land in hopes of better avoiding tearing, but the combination of trying to decide to get out of the pool and the fact that I knew I was going to be miserable and freezing conspired to keep me in, rushing me past the point when it was possible to change.

Things started going extremely fast. The urge to push felt like the need to surface after realizing you are accidentally too deep and too long under water, and it was all I could do to heed Michelle’s suggestion that I hold back, and slow down. The thought crossed my mind that I could just push once, really, really hard and blast the baby out, perineum be damned, and be done with labor. (Fortunately I was still present enough not to try it.) Once or twice I reached deep and found the wherewithal to pause and slow down, hold back, breathe, rest for a moment. And then off again, involuntary, my body furiously pushing. I held my hand between my legs and Michelle supported me from behind. A few more surges and baby’s head was out. A pause. I asked if I could just push and be done, and then I did it, and she was here.

Michelle handed you up to me through my legs and I held your body outside of mine for the first time. Just like with your sister, your cord seemed too short, and Michelle unwrapped it from your neck, giving me the needed length to bring you up to my heart. I don’t remember what I said, but I remember the feel of your tiny, strong, wet body. You took a moment - I think Michelle may have reached over to stimulate you just a bit - and then you cried, tiny loud cries, actually shouting the sound “waa, waa” as though you were reading from a comic about what babies say at birth.

I got out of the pool almost immediately and your dad and I marveled at you as Michelle and the backup midwife Sue bustled about, invisibly getting your APGARs and monitoring my bleeding, which had them slightly concerned. A shot of pitocin and some tough-love uterine massage were not enough to take my eyes off of you, impossibly tiny and strong, with a perfectly round head. I was overcome with a desire to lick you clean and after several long moments decided you were my little mammal baby, and gave you just a tiny swipe. (I later confessed this to Aaron, somehow thinking he might not have noticed despite being about a foot away. He said, “I know.”)

The rest of the immediate postpartum is a blur. I held you up to my breast for the first time and you latched on beautifully, as though you’d done it a hundred times before. I delivered your placenta. Michelle asked me to cough and I did so right in your face because I didn’t think to look away from you. (You repaid me by sneezing in mine a few hours later.) Concerns about my bleeding abated. Your sister woke and met you, tentative, sleepy-eyed, holding Dada’s hand. You stretched and snuggled and nursed and joined us on this side, pink and hairy, present, wise-eyed, gorgeous, Georgia.

Monday, June 30, 2014

See you in a while.

Well, first I got all caught up on Facebook and Feedly. Then I swung by Twitter, Tumblr, and Instagram and finally, went on a little Buzzfeed binge. Now I am going to write this post.

And then I am going to take an internet break.

I have been thinking about the many good and bad things the internet has brought to my life.

Good things like, oh you know, my interests in birth, feminism, and social justice. Help in trying not to be a racist. An awareness of the dik dik and unschooling. xkcd, The Fat Nutritionist and Hyperbole and A Half, Swistle and Blue Milk. Stuff. Whatever. Lots of good concepts about parenting. Really a lot of completely amazing people that I would love to meet in real life one day but wouldn't ever have to because they are my very real internet friends and acquaintances, and that's enough.

But I have also been feeling lately that the way I interact with the Internet is stealthily stealing something from me. I feel like I used to be a lot more curious and motivated to learn. I used to have a much longer attention span. I think maybe the instant gratification and instant answers on the internet are ... sapping me somehow.

This isn't "I used to read real books," although I'm hoping I can use some of my non-Internet time to read more books.

It's also not "I should make more real friends," and in fact one thing I'm hesitant about here is that I really do want to make some local friends and frankly the best place to do that, by far, is online. What, am I going to place a classified ad? Hang posters?

This also isn't "purify my life." I LOVE the internet. I LOVE the places and people I have found here. I'm not fasting or cleansing. It's more about the way I sit (literally and figuratively) online, the way I compulsively check my phone, the way I decide on a project - like this week, rice-cooker meals - and then open 12 different tabs and spend several hours browsing through them and following links, and then never make any rice cooker meals because I never decided what leads to follow. It's a problem of scope and approach and not content or purpose.

The thought of an Internet break has been kicking around in my head for a while now. I half-joked with Aaron that for my upcoming birthday I wanted us to go for a day without using our phones or laptops. But first off, I don't need to rope him into my issue, and second, taking a day or a weekend off and re-evaluating was a little too ... big tent revival for my purpose here. I want to frame this for myself as something other than temporary deprivation followed by new resolve.

I am trying to think of this as freeing. I am giving myself a while to be free of the demands of keeping up with what's happening online. I am just going to be out of touch. I'm going to miss some great articles. I will not be the first one to tweet the link. Important things will happen for people I care about and I will not know about them right away. I guess? I'm not actually sure what will happen, because I have never, ever done this before.

I'm resisting the urge to be a pedant about my project. I'm not making rules or setting time limits. I'm not blocking sites or getting Aaron to change the wifi password. And in fact, because I do want my life to be semi-functional and do not want to be completely isolated, I'm not being a purist about it. I'll keep up on my email. I'll use data on my phone when I need it. I will probably hop on Facebook here and there to see if my old friend from middle school has had her baby yet or not. I will Skype with family and gchat with my bestie. I'm going to keep doing the Daily Frances because it is my favorite thing ever. I'm getting set up to do some volunteering for a great organization and I will obviously use the net however I need for that. It's all good. But I'm going to leave my laptop off and in a drawer instead of open at the kitchen table. I'm going to toss the phone in the bottom of my purse instead of keeping it attached to my palm. I'll sit on the floor and read a novel while the baby is playing instead of trying to keep her away from my lap(top). Or maybe I'll just sit and think.

Sooooooo throw me a bone, if something exciting happens for you, I would love to hear about it via email or text. Or if nothing exciting happens but you just want to say hi. Or if you took the best selfie and I shouldn't miss it. I care about you! Email and text me! My email is my first and last name at gmail. Email me for my phone number.

And wish me luck or self-discovery or whatever. I will now proceed to not check my blogger stats about how many people visited this post.

See you in a while.

Saturday, October 5, 2013

MPH Project - Part 3

We have arrived at part 3: sophisticated commentary by yours truly.

If you have been reading along, you may have already noticed that the bullet points in Part 2a and Part 2b do not have much overlap. In other words, the things that The Man measures and reports about maternity care are not the things that The People say they care about when you ask.

  • We measure and report things like obstetric trauma rates, cesarean rates, low birth weight rates, and elective early delivery rates.
  • We say what's important to us are things like communication, control, and relationships.

I don't think it's the case that consumers don't care about things like obstetric trauma. It may be the case, though, that consumers consider safe, quality, evidence-based care to be a given, and hence don't even think to list these things when asked what's important.

You might say, then, that the solution to the mismatch is to educate people, to teach consumers that safety and quality in their medical care is not a guarantee, and show them how to use the existing measures to make educated decisions about their care. This is the tactic that the maternity care shared decision making initiative I was working on is taking, and I think it's really valuable.

But I think the mismatch is symmetrical. It's not just important for consumers to "wise up" and appreciate the technical safety and quality data. It's also important for those who are measuring and evaluating maternity care to listen to consumers on the subject of what they want to know.

I call this "patient-centered quality measurement," and I see it as a good fit with many of the other activities that e-patients and patient advocates have undertaken in recent years. "Nothing about me without me" should include the way you measure and evaluate the care I am going to receive.

Consumers clearly want to know about more aspects of maternity care than are currently measured. Can you imagine what it would be like if you really could look up information about how patient-centered your prospective hospital was, or how good a communicator your potential midwife was? (It's always a little hard to tell, but I don't think this is just me geeking out - this would be really engaging, right?)

PS. I said I was going to review my recommendations to the federal government, and I don't want to disappoint, so here they are:

1. Adapt the federal Hospital Compare patient experience survey (HCAHPS) for maternity care, start oversampling maternity care consumers, and report these results separately.
2. Create a new set of AHRQ measures about patient experience/patient-centeredness. Involve consumers in this project!

MPH Project Part 2b

Next comes the interesting stuff (depending who you ask, I suppose). I did an informal literature survey trying to answer the question "What do maternity care consumers in the US say they want from their care?"

This question was intended to be an answerable proxy for the un-researched question I really wanted to know the answer to: "What kind of quality measurements do US maternity care consumers want?" (And the followup question, "Are those desires being met by current quality measurements in maternity care?")


The scope of the paper needed to be fairly circumscribed, but interestingly, limiting the data to US only was almost too much - I ended up with under a dozen papers, several of which were not general populations (people who gave birth at home, grand multiparae).

Nevertheless, I was able to draw out some recurring themes from across these studies, most of which were survey- or interview-based. Here's the cheat-sheet version.

Maternity care consumers care about:
  • the character of the relationship with their provider: this person should be a good listener and communicator, and be validating and supportive. She should enable shared decision making and personalize each interaction.
  • experiencing control: the concept meant different things in different studies, but consumers generally wanted to experience control in their maternity care. For example, this could mean feelings of personal security or decision-making responsibility, or the ability to determine the course of labor and birth.
  • having enough information: consumers wanted to be given enough information to participate in decision-making, and they wanted to receive information from all of their care providers, including labor and delivery nurses.
  • patient-centered care: consumers wanted their care to be organized and delivered in a patient-centric way. For example, providers should listen carefully, show respect, and spend enough time on each visit.
  • safety: interestingly, the desire for safety was mentioned only in the articles studying people giving birth at home and grand multiparae.
Next time: What do we make of the fact that (most of) these concerns are essentially not at all addressed by current quality measurement?