There has been a woman in labor here at Shanti for the past two days. Viola looks about my daughter Anna’s age, but she is actually 25, and this will be her third living child. She is petite, commited to this labor, and really really working hard. She is laboring out of site of the training, although we catch glimpes of her walking around the beautiful grounds, working with through her contractions with the help of an older woman. I assume this is her mother-in-law, as they seem to be the most common labor attendants here. She has captured all of our hearts; her labor is difficult, and she is so so tired.
We always say that third babies are the wild card. While they are housed in an experienced uterus, it is one who has been stretched out. Third babies can get into all sorts of wonky positions, causing a longer (and depending on the position of the baby) more intense. labor. Early this afternoon, one of the midwives asks if I would check her, as they would like to know if I can ascertain the position of the baby, and maybe give some suggestions to help.
When I enter the birth room, Viola is lying on a plastic sheet, moaning slightly, even when she is not actively contracting. She is having a very difficult time relaxing between contractions, and she is holding her lower back. I note where she is lying (her left side), and that she taps out a quick staccato rhythm with her right hand when she contracts. She is sweating, shaking, and she is deep deep into that place we call Labor Land. She does not glance up at me as I sit silently on the bed next to her, just letting her get used to my presence. Her belly is flat in front, from just above the umbilicus to a few inches below. Her contractions are irregular, between 3 and 6 minutes apart, although when they do come, they are very strong. I ask her softly if I can feel her belly, and she nods quickly, just once.
Now, so far, my “examination” of her has been pure observation, and observation is the heart of doula work. If she’s clutching her back, there’s a good chance it probably hurts even in between contractions. Lying instinctively on her left side is not only good for getting the maximum amount of oxygen to the baby, but can also help a baby rotate and come down into the birth canal. And a flat front belly can indicate a baby who is hanging out in the occiput posterior position, also known as “sunnyside up.” The baby’s spine is resting against the mother’s and this bone on bone action can cause the dreaded “back labor.” And, from the shape of her belly, I can tell that the baby has not yet dropped down into the pelvis. This is not uncommon in women who have had prior babies, so it doesn’t really concern me. From the length of her labor, I can theorize that this baby is probably not only sunnyside up, most likely acynclitic as well, a situation where the baby’s head gets cocked off to one side or the other. This makes it harder for the baby to descend, as the surface area of the head is increased.
All of these things can be helped along (sometimes) by positioning exercises, which, coincidently, is exactly what we are teaching today! So convenient. The midwives have already used some of the exercises we showed them, but here is a great chance to illustrate how to read a labor, how to put all these little clues together and make a plan to get this baby shifted. I knew that as soon at the baby worked out how to drop into the pelvis, Viola would not have to push long. I could tell from the size of her belly and some gentle palpation that this was not a giant baby, and if she had birthed two full term babies previously, there should be plenty of room.
At this point, I pretty much knew all there was to know, and an internal exam was just going to be a formality. She was most likely almost through dilating, but the baby was still high in the pelvis, trying to turn its head this way and that, searching for the way that fit him or her best. The trick was going to be to give her enough time, and keep her energy up enough to let her body and her baby do their work. She was very very tired, although she was eating pineapple and peeing frequently. (This last is important, as a full bladder can impede a baby’s descent. Think about how close the bladder is to the uterus, and you can see why. For those readers without a uterus, I’m sure you can imagine.
I grab a glove from the box, and ask her permission to examine her. She nods once and rolls over. Sure enough, she is 9 cm dilated, but the baby is still floating. As hard as she has been working, she’s going to have to do a bit more. I explain how to position her on her left side, with her leg raised high on pillows, almost lying on her baby. In the western obstetrical world, we call this position Modified Sims. In Viola’s world, we call it resting comfortably. I give the midwives a few more suggestions for when Viola is able to participate more actively, including the Captain Morgan (one leg on a chair, the other on the ground, swaying gently through contractions) and hands and knees, leaning over one of the new donated birth balls. (Thank you, Simkin Center in Seattle!!). I smile at her, check the heart tones of the baby to ensure that he or she is liking this position, (heart tones are perfect!) and leave her with the Ugandan midwives.
This goes on all afternoon. Periodically I would be asked to check on her, and periodically I would go in and hang out with her, offering suggestions as we went. Eventually the midwives start an IV, just to keep her hydrated in the Ugandan heat. We also used the rebozo with her, and put her through a million different other positions. She was a trooper though all of it. Eventually it was time to leave, though, and Viola was still laboring. I was certain she would either deliver that night, or be transported for an obstructed labor.
The next morning, I was delighted to find that she had birthed during the night. Hooray!! And sure enough, it had only taken two pushes . Baby just had to find the way. As Melinda and I sat admiring the baby, and telling Viola how wonderful she was, I asked his name. “Jane, I want you to name him,” she replied, smiling. I was shocked and honored. Together we decided on Patrick, after my beloved husband. It is a gift to get close enough to someone that they want you to name their baby. A true gift to connect on the most basic womanly level, though birth. I hope Patrick lives a long and happy life. I know he has a wonderful family, and I hope I can see him next time I return to Shanti.