The door that opens both ways.

The door opened gently this time, and when it closed it was with a whisper. My father's body lay in the stillness of no life and his long, irregular breaths that had filled the night were silent at last. Surrounded at home by his grown children and bathed in the love my mother had given him, he was on his way. It was 4 AM.

Just eight months earlier at 4 AM the waters of love holding the baby inside my belly opened gently, announcing that the time had come to give birth. I felt the door open then, too. In the next few hours, it remained ajar As I labored, I could feel the ebb and flow of the life/death force swirl around me. When Shawn's spirit led his body into the world and my waiting arms, I heard the door close firmly. The warm baby on my breasts was full of life and here to stay.

Today, fifteen years later, Shawn's birth and my father's death are bittersweet memories off in the distance. In my work supporting birthing women and their families, I appreciate the lesson I learned back then. Birth and death use the same door. They are both opposite and alike.

In teaching the Childbirth Assistant Workshop I tell my colleagues that "you cannot do this work without one day encountering death. The truth is, babies sometimes die." I can see on their faces a rainbow of emotions from acceptance to denial and the ever familiar "it won't happen to me." But it will - and we need to be prepared. In attending over 150 births during the last five years, I have encountered the death of a baby three times. Twice during the birth and once at three months postpartum with a twin dying of SIDS.

Regardless of the scope of your practice and the services you provide, it is important to think now about what you will do when death comes with birth. As birth assistants and/or childbirth educators, we are in a position to make an invaluable contribution to those we serve in a time of crisis. Just as we strive to fulfill a need not addressed by the medical culture by advocating the normalcy of the birthing process, we can provide similar support as well in addressing death as a natural part of the cycle of life.

Think About Our Culture

We live in a society that worships the myth of the "perfect baby." If we just do all the right things, surely our baby will be perfect. Even those of us who prefer to avoid the technical approach fall prey to this illusion. So we pick the "right" doctor or midwife, choose to birth at home or in a well decorated birthing center or hospital, we take our prenatal vitamins and chlorophyll and attend those exercise classes with a feverish commitment. We go to our childbirth education classes, practice breathing and relaxation and we read, read, read. Surely, with all this preparation nothing can go wrong. Right? Usually.. but not always. Anyone, including you and I, can conceive, carry and give birth to a child who does not live. This seductive notion that we can control nature leaves us thinking that birth is not supposed to ever involve death.

Secondly, death is hidden in our culture. Over 80% of our loved ones die today behind closed doors and away from their families. We do not live in a village where we watch the ebb and flow of life's tide before our eyes, so we grow up with little or no experience of death and we're left learning that it mostly happens only to older, sick people - and it certainly is not supposed to happen to babies.

A third aspect worth pondering is our love affair with life at any cost. We try, more than any other country, to save infants who are born facing terrible odds for survival. Because we have the technology and the know-how we work to keep extremely premature babies and/or those born with multiple anomalies alive at almost any cost. While I am neither condemning nor condoning this approach (if it were my baby, I'm not sure what I'd do), I can see that it helps to cement into place our culture's belief that babies are not supposed to ever die. And the truth is they sometimes do.

Learn About Yourself

So how do we prepare ourselves for what we really, deep inside, hope we will never have to face? First and foremost you must learn about yourself, about your own beliefs and your attitudes. Self realization is about encountering and owning where you are at right now. To do this, expose yourself to the reality of babies dying. A good place to start is reading the "personal account" books or articles that are available. I personally like William Kotzwinkle's Swimmer in a Secret Sea There was also an excellent account in two parts in the California Association of Midwives' (CAM) publication - "The Story of Zachary" and "The Thirty Minute Miracle". Many other inspiring personal accounts exist as well. For an excellent bibliography of books and articles, see Empty Cradle, Broken Heart by Deborah L. Davis, Ph.D., which is in itself a terrific resource for your library.

In addition to reading, work to meet and talk with families who have lost a baby. There arc support groups who may be willing to allow you to attend, or in some way share their knowledge with you. Don't wait until the first time you are involved in a birth/death to allow yourself to experience some of the complex emotions you may feel.

Seek Opportunities For Training

Start with your local hospice organization or any groups specifically created to support families that have experienced the death of a child. They quite often have training for volunteers and counselors that you may be able to tap into. Also check with your local hospital regarding their nursing education programs. Seminars discussing such issues as the quality of life and prolonging life with machines can also be very helpful in your training. Even though they may focus on the older person in our society, the issues are often the same with infants.

When possible, attend statewide, regional and national conferences for childbirth educators, midwives and birth assistants. Almost every conference addresses the issue of death and grieving in one of its workshops.

Finally, if you can't find or get to an existing workshop or lecture, create one on your own! Find a professional who works in this field and invite them to speak. Charge a small fee to cover your costs and invite other educators and birth attendants in your area. We do this in my town and find that most professionals are happy to speak for a couple hours as a community service.

Get To Know The Literature

In addition to reading personal account stories or books, read one or two publications that were written for grieving parents. Then look over one of the many books written for the "professional" (aimed at clergy, therapists, social workers) and familiarize yourself with what's available should the time come for you to support a family in their loss.

You can also make a file for yourself of articles, poems, or stories that you find most helpful. At some later date, you may use them as a resource for your families. Also make files on SIDS, twin loss, miscarriage and other specific issues. There are many facts to know that influence the parents in each of those scenarios. My own personal experiences have twice included the loss of a twin. There has been extensive research and thought put into the difficult paradox these parents face.

Get Your Resources Together

You should be able to get a good start on a resource list from your reading. Include national, state and local organizations, support groups, and/or foundations. In addition, if you will be working with families planning hospital births, meet the staff members in your hospitals who provide services to families during loss of a loved one. This is most often a social service worker, licensed clinical social worker or the like. Make an appointment with them, explain the work you do and ask what is usually done in that hospital when a baby dies. If you are working in a home birth setting, discuss the protocols of the midwife with whom you are working.

A final, excellent resource is other families who have experienced the loss of a child. While not all families are ready to share themselves with others, for some it is a form of healing. The brave young mom I know who lost one of her twin daughters at three months of age to SIDS had mastered nursing twins by that time. A few months after the death of her daughter, I was working with another mom who was having great difficulty trying to figure out how to get both twins on the breast when she was home alone with no help. I got the two moms together and with tears in my eyes watched as they shared the wisdom of mothering together: the newest mom finally bringing both babies to breast on her own, the older mom holding the newborn twins in her arm and kissing them with a deep joy that only deep sorrow could have made possible.

Make A Birth/Death Plan

Make a plan for yourself of the possible actions you would take in the event that a family you are supporting loses their baby. Chances are, in the moment, you will be overcome by shock and your own emotions and not necessarily be able to remember all that you can do for them.

As part of your plan, learn about your client's spiritual beliefs. If you have a chance to get to know them ahead of time, find out about their support system - where their families are located, who they use for support in their community, etc.

Finally, learn about legal regulations in your area. Under certain circumstances an autopsy may by "required" by local authorities. If you know something about this aspect, you may be better prepared to support your family with addressing some of the difficult issues facing them.

A Birth/Death Story

When they took mom to the operating room for the emergency C-Section, I knew then that it was possible her unborn child might not live through his or her own birth. I stayed with dad in the hallway outside the surgery room. I explained to him everything I saw being done with any added opinion. When I saw the operating team using a hand-held Doppler to try and find the baby's heartbeat, and that I couldn't hear one - I told him that. When his still, peaceful daughter came up out her mom's tummy and they began neonatal resuscitation on her, I told him exactly that. As we watched for more than twenty minutes, I let him know that they were still using a device to breathe for her and that they were still using cardiac compression on her heart. The CPR and cardiac medications being injected, along with no audible heartbeat from the monitor, let us know she had not yet "started up on her own."

When the pediatrician came out of the operating room, he signaled to me to follow. Once around the corner he fell into my arms crying. Did the father know? I told him what I had been doing and that I felt that dad knew but that I had not said the words, that "his baby was dead." I then went and found a clean room not in use and brought the dad and pediatrician together and left them alone. Mom had had general anesthesia and would not be fully aware for an hour or more.

I then spoke with the staff - with all of us crying and comforting one another - about getting a private room away from the other maternity rooms where the dad and mom could be with their baby. While that was being set up I spent to the nursery where the young beautiful baby girl lay in stillness. I discussed with the nursery staff and pediatrician the idea of keeping the baby wrapped in warm blankets to keep her warm for her mom and dad. They gave me their okay and so this was done about every fifteen minutes for the next two hours.

I helped the dad into his room and he sat in a rocking chair with the sun shining through the window behind him. When he let me know he was ready, I went and got his daughter and brought her to his waiting arms. I stayed with him for a few minutes. Together we unwrapped the blanket and I told him it was okay to look at her perfect body. I pointed out her toes and her hair and her fingers. I then let him know I was going to take some pictures for him and his wife and that they could decide later if they wanted them or not. He said okay. Then I left the room and closed the door behind me. As if waiting for the blessing of privacy, he finally let loose his cries of mourning. I set myself up in the hall to guard his door, making sure he was given this exquisitely precious time without interruption.

Later he wanted the baby taken back to the nursery where we continued to keep her warm. The pediatrician and I talked with dad to see how and when he wanted mom to be told. Dad wanted to tell her when he felt she was ready and then he would signal me to get their daughter Soon mom was brought into the room from recovery where she remained for many more minutes in that half-conscious, dream state of post-anesthesia Dad wrapped his anti like a cover over her head and lay his face next to her on the pillow. Time passed with his sweet whispers gently waiting for her to swim into awareness. Finally the anguish washed across her face and he nodded to me. I brought the still warm bundle that they had waited nine months to hold and put her gently into their embrace. Again, I took a few pictures and then helped to usher everyone including myself out of the room.

I understand from the staff that they remained together for six hours. I left soon thereafter and made frequent visits in the next week. When I went home that day, I wrote down all of what I remembered of that birth. I let the parents know in the days afterwards that I had done that and that if they ever wanted it, it was there for them. A bout a year later, they did ask for my story and let me know how important their pictures were for them. We did not remain "close" but we did stay in touch occasionally. When they were pregnant the next time, they asked me to be with them again. In the end I was out of town for the birth, but today they carry a beautiful baby son in their sling and I see them about town often.

This is just one story. Not every story of a family left with empty arms ends with a new child being born. Each encounter with a baby's death is as unique as we know each child's birth is. I think that those of us who have chosen to work around birth have a love for the unpredictable nature of it all. It keeps us dancing a new dance in partnership with each family we serve. I hope that my words will help to enable and empower you when you find you must dance the dance of a birth that includes a death. Keep in mind that life's door opens both ways. It's supposed to.

Mayri Sagady is a national instructor for both IH/IBP's Childbirth Assistant and Childbirth Educator Training Workshops. She is an RN, Childbirth Educator, Lactation Specialist and Professional Labor Support Provider through Birth Support Associates in Santa Barbara, California.