a doula combining Science and spirituality, research and Intuition..

Archive for November, 2014

Bonding and attachment

Issues with bonding and attachment are certainly not new. In past times witchcraft or faeries were often blamed for leaving ‘changelings. This poem by John Greenleaf Whittier is an interesting story with a happy ending after intervention (a past times version of the work of psychotherapists like Dr Amanda Jones perhaps http://www.neuropsicoanalisi.it/NPSA/Jones_Amanda.html http://www.independent.ie/life/family/mothers-babies/i-thought-that-my-baby-was-a-monster-26344972.html)

For the fairest maid in Hampton
They needed not to search,
Who saw young Anna Favor
Come walking into church,-

Or bringing from the meadows,
At set of harvest-day,
The sweetness of the hay.

Now the weariest of all mothers,
The saddest two years’ bride,
She scowls in the face of her husband,
And spurns her child aside.

“Rake out the red coals, goodman,-
For there the child shall lie,
Till the black witch comes to fetch her
And both up chimney fly.

“It’s never my own little daughter,
It’s never my own,” she said ;
“The witches have stolen my Anna,
And left me an imp instead.

“Oh, fair and sweet was my baby,
Blue eyes, and hair of gold ;
But this is ugly and wrinkled,
Cross, and cunning, and old.

“I hate the touch of her fingers,
I hate the feel of her skin ;
It’s not the milk from my bosom,
But my blood, that she sucks in.

“My face grows sharp with the torment ;
Look ! my arms are skin and bone !
Rake open the red coals, goodman,
And the witch shall have her own.

“She’ll come when she hears it crying,
In the shape of an owl or bat,
And she’ll bring us our darling Anna
In place of her screeching brat.”

Then the goodman, Ezra Dalton,
Laid his hand upon her head :
“Thy sorrow is great, O woman !
I sorrow with thee,” he said.

“The paths to trouble are many,
And never but one sure way
Leads out to the light beyond it :
My poor wife, let us pray.”

Then he said to the great All-Father,
“Thy daughter is weak and blind ;
Let her sight come back, and clothe her
Once more in her right mind.

“Lead her out of this evil shadow,
Out of these fancies wild ;
Let the holy love of the mother
Turn again to her child.

“Make her lips like the lips of Mary
Kissing her blessed Son ;
Let her hands, like the hands of Jesus,
Rest on her little one.

Comfort the soul of thy handmaid,
Open her prison-door,
And thine shall be all the glory
And praise forevermore.”

Then into the face of its mother
The baby looked up and smiled ;
And the cloud of her soul was lifted,
And she knew her little child.

A beam of the slant west sunshine
Made the wan face almost fair,
Lit the blue eyes’ patient wonder
And the rings of pale gold hair.

She kissed it on lip and forehead,
She kissed it on cheek and chin,
And she bared her snow-white bosom
To the lips so pale and thin.

Oh, fair on her bridal morning
Was the maid who blushed and smiled,
But fairer to Ezra Dalton
Looked the mother of his child.

With more than a lover’s fondness
He stooped to her worn young face,
And the nursing child and the mother
He folded in one embrace.

“Blessed be God !” he murmured.
“Blessed be God !” she said ;
“For I see, who once was blinded,-
I live, who once was dead.

“Now mount and ride, my goodman,
As thou lovest thy own soul !
Woe’s me, if my wicked fancies
Be the death of Goody Cole !”

His horse he saddled and bridled,
And into the night rode he,
Now through the great black woodland,
Now by the white-bleached sea.

He rode through the silent clearings,
He came to the ferry wide,
And thrice he called to the boatman
Asleep on the other side.

He set his horse to the river,
He swam to Newbury town,
And he called up Justice Sewall
In his nightcap and his gown.

And the grave and worshipful justice
(Upon whose soul be peace !)
Set his name to the jailer’s warrant
For Goodwife Cole’s release.

Then through the night the hoof-beats
Went sounding like a flail ;
And Goody Cole at cockcrow
Came forth from Ipswich jail.

Prolonged latent labour

A recent article appeared on my fb feed, ‘My clients body is broken’ (http://tucsondoulas.com/clients-body-broken/)
There is much I agree with what Angela has said, rest, relaxation, reassurance should be the first things any doula suggests when labour is slow to start.
We have all seen eager first time mum’s, so excited that labour has started that they stay up all night pacing with a tens machine when contractions are still very irregular or far apart. If you add in a second night like that, you can end up with an exhausted mother, especially if she hasn’t eaten much with all the butterflies, desperate to go into hospital and get them to do something to get her baby to come out. This is not an ideal recipe for active labour!
This got me thinking about one of the claims that was made in Angela’s article:

“Prodromal labor is not a problem that needs to be fixed. It is normal!”

How many women experience a latent phase of labour and how long does this usually go on for before active labour begins?

Many signs can proceed the start of labour (e.g. discharge, bloody show, nausea, back ache) but the latent phase of labor is seen to commence with the onset of regular contractions and ends when the rate of cervical dilatation begins to accelerate (active phase) . Contractions in the latent phase of labour can be far apart or can get closer together when women are active and slow down when resting.
Greulich (2007) stated that approximately 5% to 6.5% of women are given the diagnosis of prolonged latent phase of labor.(Using Friedman’s original definition of prolonged latent phase as greater than or equal to 20 hours in nulliparas and 14 hours in multiparas.) and a study by Chelmow (1993) that used a definition of >12 hours for women having their first baby and >6h for women having a subsequent baby) found an overall prevalence of 6.5%

Women with a prolonged latent phase that cannot rest due to frequent or painful contractions that disrupt sleep can become exhausted. Women can end up wanting to transfer from planned homebirth for analgesia purely to get some sleep and I have seen women falling asleep in birth pools in between contractions in the second stage, only to be woken in a panic a couple of minutes later, forgetting where she is and what she is doing.

Recent research has found that length of latent phase duration as well as food intake and the amount of rest and sleep during the preceding 24 hours are independent predictors of [active] labor duration (Dencker 2010)
Chelmow also looked at outcomes after prolonged latent phase of labour and found women with prolonged latent phase labor are at higher risk of cesarean delivery and longer hospital stay and their newborns are more likely to require neonatal intensive care unit admission, have meconium at birth, and have depressed Apgar Scores.

What happens when women go to hospital?

Early admission to hospital (in latent phase) has long been recognised as a risk factor for subsequent labor abnormality and intervention (Bailit 2005) including prolonged labour, more need for analgesia, increased rate of caesarean section, increased PPH and postpartum hospital stay (Janna 2013).
Like the chicken and the egg it is difficult to interpret whether those interventions are due to complications leading from prolonged early labour or from extra intervention due to the early admission. For some more discussion on this on the ‘Midwives thinking blog’ https://midwifethinking.com/2013/11/13/early-labour-and-mixed-messages/

In a another recent study women indicating that they had been in labour for 24 hours or longer at the time of hospital admission were at elevated risk for caesarean birth (Janssen 2014)
Many women are turned away from hospital (either to try to reduce the risk of unnecessary intervention or because the unit does not have room or staff able to care for women who are not in active labour. This can be disheartening for women who are in considerable pain and distress. Hopefully those with a doula will have had more support in the latent phase. However I have read of doulas that refuse to see their clients in early labour, partly so as to reduce the number of people ‘watching and waiting’ (and the subsequent pressure on women to perform by going into active labour (when this is out of their control) and partly to conserve their own energy in what might be a long labour.
This is not much help to women who have been in pain for a considerable time, feeling unsupported by a midwifery service who tell them they are not really in labour and to go home and take a painkiller, and a doula that will not support them in early labour.

  • A period of time where women are unsure if labor has started is normal and may include a range of signs
  • A period of latent phase of labour where contractions have started but are far apart or infrequent is common
  • During this latent phase of labour women have better outcomes if they rest, sleep and eat normally and avoid admission to hospital (unless they have other risk factors or worries about their babies welfare like reduced movements)
  • Women that experience prolonged latent phases, especially with painful contractions that prevent sleep and food intake may need additional support and may be at greater risk for longer labours and more intervention during the birth
  • Prolonged latent phase may be associated with malposition
  • Women with prolonged latent phases may need additional support from their birth partners, including a greater range of comfort measures and support to aid fetal rotation so that active labour may begin

Maybe helping mothers move in ways that aid fetal rotation and so reduce the length of time in a prolonged latent phase is a comfort measure?

I think so
Greulich, B. and Tarrant, B. (2007), The Latent Phase of Labor: Diagnosis and Management. Journal of Midwifery & Women’s Health, 52: 190–198. doi: 10.1016/j.jmwh.2006.12.007
Chelmow, D, Kilpatrick, SJ, Laros, RK Jr. Maternal and neonatal outcomes after prolonged latent phase. Obstet Gynecol 1993; 81:486.
Bailit, J. L., Dierker, L., Blanchard, M. H., & Mercer, B. M. (2005). Outcomes of women presenting in active versus latent phase of spontaneous labor. Obstetrics & Gynecology, 105(1), 77-79.
DENCKER, A., BERG, M., BERGQVIST, L. and LILJA, H. (2010), Identification of latent phase factors associated with active labor duration in low-risk nulliparous women with spontaneous contractions. Acta Obstetricia et Gynecologica Scandinavica, 89: 1034–1039. doi: 10.3109/00016349.2010.499446
Friedman EA. Labor: Clinical evaluation and management. New York: Appleton-Century-Crofts, 1967.
Janna, J. R., & Chowdhury, S. B. (2013). Impact of timing of admission in labour on subsequent outcome. Community Based Medical Journal, 2(1), 21-28.
Janssen, P. A., & Weissinger, S. (2014). Women’s perception of pre-hospital labour duration and obstetrical outcomes; a prospective cohort study. BMC Pregnancy and Childbirth, 14(1), 182