Time in a Bottle
Editor’s note: This article first appeared in Midwifery Today, Issue 97, Spring 2011.
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Time is a frequently unnamed and unacknowledged medical complication plaguing most births currently taking place in medical settings. Considering the fast-paced nature of modern American culture, perhaps it’s not unexpected that the issue of time is having a never-before-seen and increasingly disastrous effect on pregnancy, birth and postpartum recovery.
Time first becomes an issue in medically attended pregnancies when the due date is established. Early ultrasounds are now the routine authority on when a baby is “due,” regardless of a mother’s personal sense or determination of her dates. This date is critically important, as it is the basis of medical expectations of when birth should occur. Perceptions of the normal window of birth have narrowed from “two or three weeks on either side of your due date” to “let’s schedule your induction if you haven’t birthed by 40 (or even 39) weeks.” It’s now common for mothers to be induced at what is thought to be 39 or 40 weeks, but what turns out to be 37–38 weeks gestation, as clearly evidenced by the baby’s weight and developmental signs. The negative consequences of these choices often appear after the immediate postpartum period, commonly leaving parents to manage these challenges alone, feeling isolated and responsible.
These early babies may be stable at birth but struggle with failure-to-thrive issues from around two weeks of age. This can lead to a domino effect. Missing fully developed fat pads in their cheeks leads to a weaker suck and, therefore, an inability to completely draw the fatter hind milk from the breasts. These babies are okay as long as milk is amply pouring based on the hormones from the placenta, but at around two weeks the milk supply becomes dependent instead on the “supply and demand” system, which requires that the breast be regularly emptied of milk. Babies with a mild suck aren’t able to accomplish this and get insufficient milk, causing an overall reduction in milk supply due to a lack of sufficient stimulation. Often, the baby’s pediatrician will advise supplementation with formula, compounding the dwindling milk supply issue due to less demand instead of more. This challenging cascade may also burden the family with nipple confusion for the baby, confirmation that the mother “doesn’t have enough milk” and plummeting self-confidence in the mother.
A rather extreme example of the power given to ultrasound scans happened to one of my homebirth clients. After initiating prenatal care for her second pregnancy with her OB/GYN, she came to me wanting a VBAC homebirth. Early on she had challenged the inaccurate due date set by the ultrasound tech but was brushed off, told that the ultrasound results were quite definitive. Knowing that her opportunity for a successful VBAC would be at greater risk if her doctor believed her to be further along than she really was, this client once again asked the staff to review her chart. Even when she pointed out that she was pregnant from a single artificial insemination (and in a same-sex relationship, guaranteeing that it was the only conception time possible), her concerns were blindly dismissed with an insistence that ultrasounds “don’t lie!” This is when the client wisely went in search of more responsive care.
Nearly all pregnancies attended by medically-oriented caregivers are colored with concerns about the baby being “overdue.” Much emphasis and care is placed on the perceived risks, including multiple ultrasounds to date and monitor the pregnancy, getting the baby out before it gets “too big,” frequent non-stress tests, amniotic fluid evaluation and scheduling for inductions that starts as early as 37 weeks.
Mothers expecting twins routinely tracked to high-risk OB practices are especially time-sensitive. Assuming the language of their OBs, they describe their pregnancies to the day: “I am 23.4 weeks.” As soon as they get to 36 weeks they immediately begin to define themselves as overdue. Several times I have asked these mothers when they are “just right?” (not stressed about prematurity or so-called postdates), and every time I’ve been met with a blank stare and shaking of the head—never!
Supporting a Timeless Journey
Encourage contact between mothers-to-be and new mothers to help them shape more realistic expectations of postpartum life. Prenatal clients can attend local (often free) support groups such as La Leche League as part of their preparatory education. Final postpartum appointments might be planned so that they overlap with another client who is due soon.
Use language that shares your expectations and gives parents a vocabulary to articulate the demanding needs of their new infant. This may be basic to many midwives, but many new parents do not have this understanding. The year of having a baby can be helpfully reframed by explaining that the newborn’s first three months are really “the fourth trimester.” Accordingly, what the baby needs is a “womb with a view.” (This is a good time to lighten the mood.) Breastfeeding consultants have illustrated this concept by explaining to their mothers that the “natural habitat” for a newborn is on the mother’s chest between her breasts.
Remind new parents that most cultures around the world have some sort of a “lying-in period,” typically lasting 30–60 days or more. I remind parents that just as we’ve found healthy birth to be exactly opposite to mainstream expectations so can we expect healthy postpartum to be the opposite of common expectations. Resting in bed, being quiet, limiting visitors and taking frequent naps are all healthy.
Matter-of-factly inform the family, especially the extended family (if you have your client’s permission), that mama is going to be encouraged to stay in bed for a while after the birth and that she’s not “being lazy!” I suggest that mamas aim for a week in bed, a second week on the bed, and a third week near the bed. This also happens to naturally limit stairs (and aid perineal floor recovery) in the early recovery period. Dads and relatives often pitch in more enthusiastically during this postpartum period when they understand its value in helping to speed recovery (there’s that time issue again!) and in minimizing infections, relapses and breastfeeding problems.
Remind them that a true six-week postpartum window allows for the placenta site to fully heal and supports minimized bleeding and stronger recovery. It can be helpful to illustrate with your hands the size of a small dinner plate, and point out that if this healing site (placenta wound) was on the outside of the body, it would be easier to understand the need to move back into normal responsibilities slowly and with awareness. Women are more likely to take responsibility for their own recovery when they understand that if their bleeding picks up or get brighter red again, it means that the placenta site has been disturbed and suggests that they’ve been doing too much.
Tell first-time parents that this really is a once in a lifetime shot. If they should have another baby, there won’t be this comparative oasis of time available to adjust and bond—they’ll have a needy toddler or preschooler running about! Use Sheila Kitzinger’s description of the “baby moon,” that wonderful analogy that compares the postpartum period with a honeymoon: the purposeful use of privacy, seclusion, being served and protection from distractions while you celebrate and expand into love.
Encourage preparation for postpartum success! Protecting time to rest and bond for all members of the family can be done in so many ways: planning ahead, accepting offers of help or hiring a postpartum doula. Some families have a potluck baby shower and ask everyone to make a double recipe, bringing one dish to pass and another to freeze.
Inform them about the Family Medical Leave Act and encourage them to check with their human resources department at work regarding time off. If they work for a company with over 50 employees, they may apply for 12 weeks of maternity leave and return to their old job or an equivalent.
Laugh with them. Tell them stories. Love them.
Attending births as both a midwife (home) and doula (out-of-home), I’ve consistently found healthy motherbabies need a 45-minute phone conversation to help them calm down and emotionally “normalize” after doctor’s appointments from 39 weeks on. This is an example of rushing pregnancy and labor and also of the many unaccounted-for hours that doulas and midwives spend to compensate for society’s complex time issues.
Time also affects the experience of birth. Births taking place in medical settings are often hurried along: to begin, to continue without pause, to begin pushing, to rush pushing, to transfer, to start an IV, to use an instrument (forceps or vacuum), to perform surgery. There is pressure to complete the birth within a certain amount of time. There is a rush to proclaim that the cord has stopped pulsating and should be cut, that the placenta be born with little or no pause after the baby and that bonding should happen quickly, all so that the birth can be wrapped up and the paperwork completed. This inability for the medical model to respect the natural or personal pace of birth has become an institutional given. Women are left to process their disappointments alone and commonly spend tremendous amounts of time, energy and money sorting out what happened.
Anecdotally, conversations I’ve had with other midwives suggest a sharp increase in the number of babies birthing with asynclitic and compound presentations, such as neonates’ hands up by their faces. Could there be a relationship to the sharp rise in mothers working right up until their due dates? Due to economic distress in the area where I practice, many mothers enter pregnancy without considering a reduction in their workload or work hours prior to giving birth. Medical complications can result. Excessive edema, anemia and hypertension from the extraordinary physical strain of carrying an extra 30–60 lb and filtering and functioning for two with about 12 pints of blood instead of eight while also trying to be mentally accountable, publically presentable and awake and alert can occur. Going into labor tired or exhausted can increase the risk of longer and more painful labors. Women who work right up to the time of birth often don’t feel ready and go “overdue” as they work with their babies to tune in and prepare. They have little time to soften before the birth—not only to open their bones, but to open emotionally, psychologically and spiritually. I often describe to moms the need to get into a “soft focus,” allowing their energetic boundaries to become sort of blurry or hazy. One of my very athletic homebirth clients responded with a smile, saying that it was as if she had become a “couch magnet!” It’s often a radical idea to these moms to suggest that during those last few weeks of pregnancy they are already spending time with their baby and that their baby needs them to be rested and emotionally relaxed for things to go well.
In teaching childbirth education over the past few decades, I’ve often illustrated the normal quiet postpartum recovery with an analogy of a mama cat and her kittens in the back of a dark closet. Until recently, a large percentage of the students had been around a pregnant or birthing pet at some point. In the most recent class I taught, only two out of 30 students had seen any sort of birth or had any idea of the normally reclusive behavior of a mother animal after having babies. YouTube, while an amazing resource, does not substitute for the sights, smells, sounds and experiences of a birth. There seems to be a lack of understanding that it takes time to get to know a baby, time to establish breastfeeding and time to recover from birth. I’ve seen more than a few fathers take time off work after the birth, somehow expecting that in addition to attending to their postpartum wives and new infants, that they would also finish their thesis or the house renovation project!
For a generation that has developed their expectations of life from the media, it can be terribly shocking to discover that life is not “back to normal” right after the baby comes out and that it truly takes some time (months, not weeks or days) for things to settle down after a new baby arrives. There is a warped sense that things should be quick and efficient. In the last year, my practice has seen an exponential rise in mothers repeatedly texting me during their labors, expressing a desire to “be in touch but not be a bother” (in spite of repeated assurances that they are not a bother and, indeed, that being available is part of quality maternity care). Social media is often a part of their lives from their postpartum beds, with Facebook, Web site posts and emails all happening in the immediate hours after birth.
This perspective is compounded by our societal expectations. Mothers in the United States are given dangerously short maternity leaves, lasting twelve, eight, and even only three weeks before they are expected to be back at work. Recently, a mom who was going back to work the next day attended our breastfeeding support group in tears. As a surgical resident at a nearby hospital, she was required to work long hours up to the day she birthed and to return to her responsibilities at three weeks postpartum (even though she had given birth by caesarean and had had a secondary surgery on her gallbladder in the same time period) in order to keep her residency. This time is too short to assure bonding with the infant, stabilization of the normal physiologically immature infant, stabilization of the breastfeeding relationship and milk supply or even full recovery from the birth. What often results are higher health care costs for both mother and infant, greater long-term health risks and a huge drain on family resources. These unbelievably short maternity leaves also dramatically increases social, cultural and medical risks such as postpartum depression and child abuse due to lack of sleep, reduced bonding and financial strain.
In this age where time-honored traditions are being lost and attempts are made to quickly integrate vast amounts of information, the welcoming of a new baby gives the family an opportunity to slow down and connect. Mothers must be given accurate information about the enormity of the work of birth, the length and demands of a full postpartum recovery, the high needs of the baby and the long-term ramifications of rushing through this critical and once-in-a-lifetime chapter in their lives. The effects of the time we spend as midwives and doulas guiding families on their birth journeys truly do build foundations for parenting, echoing deeply in women’s lives forever.
Photos provided by author