About Those Difficult Births.

When the call comes in, she may be crying. Often she is quiet, withdrawn, confused. She describes the labor and how it didn't go as expected. She describes the loss of control, the feeling of being utterly without power. Sometimes she talks about horrific things that were done. It is not unusual for her to think that either she did something wrong, or there is something wrong with her. She questions her ability to ever do this again.

Who am I describing? A woman who had a difficult birth? No. I am describing you. I am describing us: labor assistants, labor support providers, birth doulas, birth assistants. We take a stand for the powerful difference our work can make. We know how to empower women and their families. We are dedicated to working in partnership with caregivers and staff members. We know that what we do works.

Then one day, blam! What's commonly called "the birth from hell" occurs and we walk away shattered, feeling guilty, and full of confusion. We wonder how we will ever be able to attend to another birth. If it was a first time mom, we will worry about all first time moms for a while. If it was a VBAC attempt, our faith in the possibility of a vaginal birth for these women will be shaken. The source of stress may be the doctor, midwife, hospital, birth center, nurse, anesthesiologist, the woman's partner, or mother. It could be fetal distress, persistent posterior presentation, a breech, twins, a hemorrhage, or a retained placenta. Whatever traits uniquely identify that birth in our minds, we will probably feel differently about those traits in the next several births to come.

Why will we do this? Because we are human beings. It is our normal way of learning combined with an instinct for self-preservation and survival. Remember that the fight or flight response occurs regardless of whether you are in actual or perceived danger. When we are traumatized, upset, shamed, or hurt as we work with unexpected, difficult, or even frightening circumstances at a birth, we cannot help but be affected at future births. That's why we often feel angry (fight) and/or want to run away and never attend to another birth (flight).

When I speak to a labor assistant who has had a particularly difficult experience, one of the first things I discuss is the concept of being a witness to violence. Not that all difficult births are the equivalent of violence. Yet, there is a parallel in what it does to someone to witness another person's trauma from a position of powerlessness. For example, think of supporting a woman who has chosen to have an epidural and then has a serious side effect, such as hypotension, fetal distress, or spinal headache. I worked with a woman who had some nerve damage caused by the administration of the epidural and limped for six months after the birth.

Another client's epidural only worked on one-half of her body during rapid, active labor--she thought she had had a stroke. Another recent client developed what is commonly called a "spinal headache." After six unsuccessful attempts to administer the epidural, the needle penetrated into the spinal fluid. In her case, it caused outrageous shoulder pain every time she pushed, and for days after the birth.

These situations, while rare, have a serious impact on us and we need to acknowledge that. We find ourselves torn between our commitment to supporting women in their choices--it's their birth--and our experience of what we've seen when such choices were made. I often alternate between feeling guilty (like I should have been able to prevent something from happening) to being angry (sometimes with the mom, sometimes the caregivers, sometimes the whole system) to a kind of grief and resignation (like I don't really make a difference, why bother?).

So, what's to be done?

First and foremost is to respect and honor that we are human beings. Our unique capacity to care and feel makes us good at our calling. The day we stop caring or become numb to the difficulties is the day we should stop doing it.

Secondly, we should recognize and acknowledge the powerful impact these circumstances have on us. Like a witness to a violent crime, it is as if the violence was done to us and we somehow participated in it. Because we witnessed, and yet had no real power to prevent it, we become a vicarious victim and wrongdoer at the same time. Knowing that, and recognizing it when it happens, is very helpful in our healing process.

Third, we usually need to grieve our own loss of expectations--expectations about the birth, ourselves, others, and this work we do. Find an outlet in which to express the disappointment, sadness, and anger. It is so important to have someone with whom you can responsibly de-brief. By responsible, I mean, keeping client confidentiality intact and not traumatizing the person who is listening to you.

Finally, forgive yourself when you're feeling guilty. Forgive others when you can. If that becomes difficult, try to see things from their perspective. In most cases you will find that no one is really evil per se. They are usually doing what they believe, really believe, is safest for the mother and baby at the birth. Someone once said that to forgive is to "give up your right to punish someone." When you are able to do that you can find new energy and begin to renew your faith in yourself and your work.

Mayri Sagady, CNM, MSN Director of Labor Assistant Training