Thursday, August 11, 2011

SHIFT CHANGE SYNDROME

I've kept myself rather out of the doula world this year. Too many worries at home mean I've cut right back on this, my favourite work, because the emotional burden is just too much; I know how to put boundaries between work and home life, sure, but as a doula one is shouldering the emotional life of another family besides one's own and right now, without going into details, my own is quite enough to be getting on with.
But when an antenatal teacher colleague rang me yesterday morning asking to have a quick chat with her brother, whose wife was in labour, I could not resist the opportunity for a bit of long-distance doula-ing.
After several dud attempts to call the father to be, who was having trouble finding a phone signal, I got through to him and from his slightly disjointed, utterly worn-out account this was the picture:
First time mum R. had been in labour about 36 hours on and off. She had gone to the nice local midwife-led birthing centre in the evening and was found to be 4 cm dilated; got in and out of the pool overnight; by 7am was up to 9cm dilated. So far so good. But by 10am the midwife was now suggesting she "go to hospital for help" (synto? epidural? ventouse? she didn't specify) because mum was exhausted and had been "stuck" at 9cm for about  3 hours and her contractions were slowing down.

His voice breaking with tiredness, the dad asked me - "Shouldn't we go to hospital? R is completely exhausted, and they keep checking the hearbeat which makes it hard for her to rest, and who are we to ignore the advice of a midwife of 30 years experience?"

Any doulas out there recognise this narrative? It's what I am tempted to name "shift change syndrome". My first question was: "How's the baby's heartbeat?"

"Oh, fine," he said. So no problem there. No medical reason, as far as the baby's concerned, to get doctors in as yet.
R was kneeling up on the bed leaning over the raised end of the bed, sucking on Entonox.

I considered the facts: simply it looks as though a first time mum has laboured well through the hours of darkness, and contractions are getting a bit further apart when three things happen at once:

1. Daylight comes, which often brings with it a slowing down of labour, whatever stage things are at.
2. Mum's cervix gets to a point of dilation where the head is no longer pressing so vigorously as before on it to stimulate oxytocin production.
3. There is a change of personnel just as she was reaching 9/10 centimetres dilation. The by now trusted night shift midwife says a reluctant good-bye at a critical moment, and a new face appears, someone who hasn't been present through the whole labour story but enters the room and puts her own interpretation on the scene. It doesn't help that it happens to be the sort of midwife who boasts that she has 30 years' experience (which means she was trained at a time when, let's face it, mothers were still expected to labour on their backs and do what the doctor told them). Even if, though, R's care had been taken over by a more subtle personality, the change in carer would have had a powerful effect on her labour, inducing the fear of the new -  which causes an adrenalin bounce and, again, depresses oxytocin production. But to be taken charge of by someone whose words suggest powerfully to R that she is not coping, that she "can't do it on her own"...catastrophic.

So I said: "OK, suppose you do go to the hospital (a 30 minute drive). It's now 10.15am. Believe me, if she wants an epidural it's going to be nearly lunchtime before she actually gets it. The drive will slow down labour. The epidural will probably slow it down too though it would let her rest. The journey might slow her labour down even more. And if it doesn't, suppose she is starting to want to push while she's in transit? That's going to be really unpleasant for her and she might as well have stayed in the birth centre."

"But she's exhausted!"
"Exhaustion goes with the territory at the end of labour," I said, and wondered if I'd been too cruel, but pressed on.

 "The truth is that it's all nearly over; and the truth is that she can do it - her body will give her an adrenalin shot when she needs the extra effort to push. What she needs now is someone there who believes she can do it -  and she needs an oxytocin boost. Why not go back in, close the curtains, give her lots of physical contact, yes, give her a big cuddle, try nipple stimulation, and tell her she can do it and that you believe in her. Oh, and see if you can get her to cut back on the Entonox - just a few puffs at a time, any more isn't helping."

He staggered off. I didn't hear anything for a while; I assumed as I usually do that I had been too cruel, that she had gone to hospital, the baby had been malpositioned and wasn't going to come down in a month of Sundays, she had required epidural, synto, ventouse, forceps, the whole dog's breakfast...

Then a text from my friend: R had decided to take my suggestion and stay put in the midwife-led birth centre - and gave birth beautifully and naturally to her baby daughter just two hours after I'd spoken to her husband. 

Hooray! If only doula-ing was always this easy! But, remember: this was a mum who WANTED a natural birth. If she had been in a consultant-led unit from the word go, I wonder if she would have been able to resist the "30 years experience" midwife's negative suggestions?

This episode has got me thinking a lot not just about how much I miss being a birth doula...but also about what happens when the midwives change shift at a hospital or birth centre birth (home birth midwives generally stick around for the duration) and I feel I should warn my clients and classes of how this will affect them.

Firstly, labour may slow down and you will need to get to know this new person FAST so that mum can feel comfortable with her. Once mum has relaxed, and "forgotten" about the new person, things will hot up again.
Increased tension may cause mum to feel pain more. Again, once she's got accustomed to the new person and relaxed again, her endorphins will kick back in.
The second shift midwife hasn't seen the mum labouring before. She doesn't know her. She needs to be filled in on what's happened. She has her colleague's notes to look at - but I believe she also needs to listen to the partner and the mum (if mum feels like talking).
So here are my tips for avoiding SHIFT CHANGE SYNDROME:

  • You have hopefully built up a good relationship with the previous midwife; make the most of this by telling her exactly what you want conveyed to her successor. A job for the partner.
  • Have another copy of the birth preferences handy; if you've written this document out in the way I advise my clients and classes to, then it will give an instant snapshot of what kind of woman you are and what your aspirations are.
  • Try and have the partner field all the questions, not the mum, so that mum's focus is not broken.
  • Ask the midwife a few questions back - you need to get to know her very fast indeed so be nosy!
  • The change in personnel, with questions and conversation, may break the mood and bring mum out of her "zone" and that's not good for the labour. HypnoBirthing couples may find it a good time to do the Birth Companion's Deepener script - or to do any other deepening script that they think will help mum to zone in. (It might impresse the new midwife, too. )
  • See the shift change positively, as a chance for a change in scene or mood that YOU are comfortable with. For example, if you are free of moorings, lines and tubes, take a walk down the corridor, visit the loo, change the music.


Don't assume from what I have written here that shift change is always a danger point. I've seen a brilliant, inspirational "second shift" midwife work absolute wonders with a tired mum who was beginning to lose heart and being intimidated by a knife-wielding consultant. She was just one of those people who had the experience and confidence to know that this was not a time for "poor old you" but a time for "OK, Kathy, you gotta get this baby out now - the doctors are talking about caesareans. I want you up and pushing. Put the gas down and get to work, kiddo." (An approach which can go disastrously wrong, by the way.)

And there have been "first shift" midwives that I was heartily glad to see the back of, as well as some who simply stay over past the end of their shift because they want to see the job through.

The NHS midwife is one of the most incredible health professionals in the universe; but she is not a mind-reader. Make her understand what YOU want and she will then be best placed to help you.

www.birthhypnosis.net




2 comments:

Kim said...

This is brilliant Sarah thanks for sharing. I'm sorry to here home life is challenging for you, hope things settle down. Would you share how you recommend writing birth preferences?

Sarah Johnson said...

Hi Kim I suggest the following main points:
Introduce yourself with a sentence saying what kind of person you are. The midwife isn't psychic yet she is supposed to be your new BF.
Highlight your main concerns about labour and birth honestly.
If you are scared of needles/being tied down/blood - say so.
Make it clear what kind of environment you want.
Say whether you are OK with students present, or not.
This is important: unless you are from abroad you already know what pain relief options are available in a British hospital. REQUEST THAT YOU ARE NOT OFFERED PAIN RELIEF - MAKE CLEAR THAT YOU WILL ASK FOR WHAT YOU FEEL YOU NEED.
Invite the midwife to MAKE SUGGESTIONS about strategies other than just offering you drugs.
Send me your email address and I'll send you a sample.