The power of being there. (Feature Article)(Cover Story).

Why did you become a labor assistant? Because of your own birth experience? To help other women achieve the kind of natural birth high you may or may not have experienced yourself? Or, without personal experience, because you wanted to accompany, assist, and affirm other women through their amazing journeys of birth? Are you able to separate your real or imagined ideal birth experience from the experience of the woman you are working with? What brought you to this work?

I probably became a labor assistant because of a cesarean section, my own. But not for the reasons you might think.

Unlike many of the women I met online during the year I spent on the ICAN (International Cesarean Awareness Network) e-mail list, who would lament that their cesareans could have been avoided if only they'd had a labor assistant present, I did have a birth doula for my first labor. My birth still ended in a cesarean birth, after a relatively short labor (without epidural) followed by four hours of pushing.

The records I got three years later showed that my baby had started out posterior, with an "arrest of descent" in the right occiput transverse (ROT) position--a difficult position for anyone to push out a baby, let alone a ten-pounder whose membranes had ruptured before any labor pains were even felt. Perhaps, posterior prevention measures or a care provider knowledgeable in how to help a baby turn could have helped prevent the cesarean. Maybe planning a homebirth would have helped, but those weren't the kind of care providers or location I had managed to choose for that birth.

I had, however, been accompanied throughout my labor by a labor assistant and my partner. But my labor assistant wasn't there when I finally arrived, at three AM, in the post-op recovery room of the hospital where my planned birth center birth had ended up. You see, when surgery was decided upon, she took it upon herself to go home. Her absence taught me a great deal.

She was possibly even more devastated by my cesarean than I was, at the time. She had never attended a hospital birth before--she "didn't believe in" them she later told me, and "you absolutely could have done it, if you'd been home." Maybe, yes. But I've often wondered, who gave her a crystal ball?

In retrospect, because I was not planning a homebirth, but rather, something I had been led to believe was "just like a homebirth" (to birth in a free standing birth center), this labor assistant was not the best match for me. (Expecting my second child I've made more careful decisions this time about who will assist and accompany me, and where I plan to birth.) At the time, she was excited to attend a birth at this center not four blocks from her home, I liked her, and I was already nearly thirty-seven weeks pregnant when I hired her.

I guess we were both extremely uninformed about the true transfer rates typical of birth centers, and about how likely I was to end up in a hospital, particularly given the apparent large size of the baby I was carrying. The birth center informed me at a prenatal visit (at thirty-eight weeks) that I could not birth there because my baby was expected to be big. They were not allowed to catch babies if they were identified as being big (in this case, over nine pounds), prior to labor. If only I had had Henci Goer's succinct information in her book The Thinking Woman's Guide to a Better Birth regarding advantages and disadvantages of home, birth center, and hospital births, and direct-entry versus certified nurse-midwives, when deciding upon my place of birth! In retrospect, I do wish I'd planned a homebirth, with truly competent care providers. But sometimes, even planned homebirths end up transferring to hospitals.

I didn't understand then, but certainly do now, that when it comes to birth, there are no guarantees. While evidence shows there are some decisions and procedures that are better than others, in the end, there are just no guarantees. My birth did not go as planned. I didn't give birth in the cozy uptown brownstone near my home and my labor assistant's home, but rather in the big downtown hospital. In a hospital where, between contractions, I had a view of lights and tall tower buildings. In a hospital where only one of the two who had both been so wonderfully lovingly with me during that amazing labor were there to greet me in recovery. And the one who stayed had never nursed a baby, had absolutely no idea how to help a baby latch on. How I wish my labor assistant, too, had been with me.

Of course, the hospital staff should have helped me put baby to breast. But they didn't. When it comes to evidence-based medicine most of us realize there is too often a huge gap between what should and what does happen in hospitals, regarding birth. Isn't part of the power of having a labor assistant knowing that she may be able to help, sometimes where hospital staff doesn't or won't?

I know it can be extremely hard to wait around for surgery to be over, when it ends up being a surgical birth. My first solo birth as a labor assistant ended in a late night cesarean. Of course I would have loved to have gone home, especially because I was working for next to nothing, had been at this birth nearly twenty hours, and had missed a major holiday celebration with my family and friends. And yet, I stayed.

And, there in post-op recovery, I seemed to be the only one willing to help the mom put the baby to breast. She didn't realize she could try to nurse after surgery and the hospital staff certainly wasn't trying to help. This new mother expressed surprise, and then gratitude, that I had remembered how much she wanted to succeed at nursing her child, that I was there to help. I will never forget this woman's smile, as we put her precious first born to her breast, lowered the lights in the room, and he suckled, eyes bright and wide, despite the drugs, despite the surgical birth. Two days later, he was nursing like a champ.

No one had helped me with nursing, in recovery, and that, more than anything, may be why I decided to become a labor assistant. My labor assistant couldn't turn my baby, but she might have helped me put my baby to my breast in recovery, if she had been there. I know she didn't like how I was treated by the hospital staff--she told me so, years later--but did that mean she had to physically abandon me?

Not only did I miss out on a vaginal birth, but, when I later realized that it had been theoretically possible to nurse my child there in recovery, I realized I had also missed giving my baby his first taste of colostrum, right after his amazing birth. My surgery scar eventually healed, but for an awfully long time this one continued to hurt.

It is such a tragedy, when women give birth surgically or have less than an ideal birth, and then have problems breastfeeding. Even though, quite possibly, different decisions all along the way to the birth may well have helped prevent whatever led to the surgery or the obstetric interventions. It does no one any good not to support a birthing woman unconditionally. It does no good to not help a mother who wants to start to nurse her baby as soon as possible, even when it's been a surgical or any highly interventive birth. But you can't help a mother nurse her baby if you aren't there.

In fact, these cesarean section and other interventive birth moms often need more support, not less, postpartum. This is especially true because there is always a higher chance of the baby being whisked away to the nursery "so that mom can rest" or to neonatal intensive care after surgical births. These are additional hurdles for a new nursing mom to overcome. And yet, with determination and support, they can be overcome. And the labor assistant can be the one to help do it.

Not seeing a birth through, as labor assistant, no matter which exit route the baby eventually takes, can be devastating to the mother.

Most of us doing this work want to help avoid surgical births altogether. Often, we can. And yet, sometimes surgical births are going to take place. And, as sorry or sad or hurt as the labor assistant may feel about the birth itself, I hope each and every one of us will find a way to put our personal critiques, anger, disappointments, and our exhaustion aside, long enough to stick around, and be there, really be there, to help our clients greet their babies, and begin to nurse them. You aren't really with woman--to support and encourage--if you aren't physically there.

There are many powers you do not have as a labor assistant in a hospital, or really any birth setting. And yet, there is one power you most definitely do have: you can be there.

Thus, I urge all labor assistants and doulas to be honest with themselves and their clients about their experience and human limits. If there are locations, care providers you can't work with, say so, before the birth! And, always work with backup, so that if you cannot stay--particularly if you still have a nursing child (or children) of your own, at home--you can at least trade off with backup, to ensure the new mom gets all the help she needs, immediately postpartum, regardless of the "exit route" used for the birth. There is tremendous power, just in being there.

And then, you might be the one who helps make a profoundly meaningful difference, in not one, but two new lives: this precious new baby's and the now new mother you've been supporting all along, by sticking around, seeing the birth through, helping them begin to nurse, and still looking into the new mother's eyes, no matter how elated or disappointed you are about her birth.

--Laura Bentz writes and mothers in Brooklyn, N.Y. On November 3, 2000, Laura birthed her ten pound, twelve ounce, VBAC daughter at a friend's home in Boston as planned, over an intact perineum, with midwives Nancy Wainer, Marialicia Gonzalez, and Beatrice Borden in attendance.

Thanks to Ellen Krug, Ilana Stein, Annmarie Kalmar, and Joni Nichols for their comments and support as this article was prepared.