Part 6 (1/2)

There may be a sense of inevitability about it: 'I had a Caesarean last time so I'm bound to have another.'

Alternatively, a previous experience may have encouraged you to do it differently this time.You may have attended birthing cla.s.ses again, chosen a home birth this time, decided to have acupuncture if you need to be induced. A distressing experience first time may galvanise you into action to prepare yourself in a different way.

The biggest issue for subsequent pregnancies is usually managing your multiple responsibilities. If you are feeling unprepared or unsupported concerning labour, it is going to be a less positive experience. It is important to recognise that you still need the active support and guidance of a birth partner. Even though there can be other children to think about, it is important that you have the support as well.This may be even more true as you may feel you are more tired, less relaxed and your thoughts are more split than they were first time around.

Complications and loss 103.

Complications and loss Complications and special care Every labour is different and there is not just one type of experience that could be considered a normal labour. Partly too complications are to do with your perception of the events. If you have a planned Caesarean section, perhaps for a breech presentation, then you may not perceive your labour to have been complicated even though you have had full medical intervention. However, there are events in labour such as your baby being 'in distress', or your blood pressure rising too high, that lead to further intervention which can in turn leave you feeling distressed and troubled by your labour. In the next chapter we will be looking at recovery from the birth and considering how these events may affect your recovery.

Even where your labour was uncomplicated, some newborn babies will need 'special care' or in more serious circ.u.mstances 'intensive care'. This may involve just a few hours of closer observation or it may involve many weeks of specialist medical and nursing care.The reasons for this type of care are most often to do with babies being born premature and being of low birth weight. Some babies are 'small-for-dates', that is, less mature than their age would suggest. Some of the other reasons for needing special care, such as breathing or feeding problems, are usually related to the baby being early or small and therefore his organs are less mature.

Jenny's story Jenny gave birth to her daughter Imogen at 32 weeks following an emergency Caesarean section. This was her first baby and she had had a reasonably uneventful pregnancy until her waters broke unexpectedly. She went into hospital where the doctors became concerned about her health and that of the baby and therefore the delivery was carried out. Jenny said that she had been completely unprepared for the birth of the baby. She had left everything until she had planned to start maternity leave at 36 weeks. Her mother, who lived abroad, had planned to come over and support her around the birth but she did not arrive until the baby was a week old. The baby was in Special Care for eight weeks and Jenny and her husband felt their introduction to parenthood was like 'caring for a sick relative'. It was hard to feel connected to this tiny baby that Jenny said seemed so unlike a baby.

She found the hours in the hospital a relentless stress followed by a 104 deep emptiness every night when she returned home without Imogen.

Three weeks after the birth Jenny's mother returned home and Richard had returned to work. It was then that Jenny began to feel depressed: her experience was so unlike her expectations. Instead of walks in the park pus.h.i.+ng the pram, she spent endless hours watching her baby sleeping and feeling like 'a fish out of water' in the inst.i.tutional environment of the hospital. Six months after Imogen came home Jenny began to have the experience of parenthood she had hoped for. As Imogen became more active, Jenny began to enjoy her daughter and this helped to lessen her sense of loss.

Stillbirth and neo-natal loss It is almost impossible to imagine the grief of parents who have lost their baby. Around 1 per cent of pregnancies end in the loss of the baby: either the baby dies later in pregnancy, during birth or in the first month of life.

Often the reasons are never clearly known, especially where the baby dies late in the pregnancy. Sometimes there are concerns during the pregnancy about the viability of the baby once he has left the womb but, more often than not, the child dies before, during or shortly after the birth without warning. The most common causes of death are serious con-genital abnormalities or very premature birth. Some women have the trauma of having to give birth to the baby knowing that he has already died. Sometimes the death occurs in labour, for example, because the cord is around the baby's neck when he enters the birth ca.n.a.l. However the baby is lost, the impact can be profound and long-lasting.

The reactions to this type of loss can be very varied and research has shown that parents demonstrate high levels of psychological distress particularly in the first six months after the loss. This may manifest as depression or anger or withdrawal from usual activities and relations.h.i.+ps.

Dealing with the loss is very individual but many parents find it helpful to keep a few mementoes such as a lock of hair, a nametag, photos or other personal items that carry special memories.

All new parents seem to need to recount their birth story over and over and this seems to be a helpful way of 'processing' or coming to terms with this very unique experience. For parents who have lost their baby, this is probably more important but often others find this difficult: they are embarra.s.sed, don't know what to say or do, or feel that they 'should have moved on by now'. What grieving parents need Complications and loss 105.

is for those around them to talk to them, to hear their story and to offer whatever practical support might be necessary. Also they need to be given time to recover. It is this factor often that leads people to seek professional help, as they still need to go over what has happened.

Parents usually feel that others don't understand and particularly don't understand how long it can take to grieve the loss of a child. A year or so after such a loss some parents do feel they are recovering but the research suggests that many are still struggling two to three years later. Recovery is also hampered by other problems, for example, if you have difficulties with your relations.h.i.+p, if generally you have a lack of support in your life or if you have had psychological problems in the past. Sometimes parents recognise that they need help because something is getting in the way of them moving on. Recovery can be hampered by feelings of guilt or blame that can be very difficult to discuss with a partner.

Sharon's story Sharon came to see me about two years after the death of her baby Alfie. Her appearance was striking, as she was dressed totally in black.

At a routine visit to the midwife at 39 weeks no heartbeat was found and a scan revealed that her baby had died. Her labour was induced and she said there was no explanation found for his death. Sharon appeared very depressed and found it difficult to talk freely about anything in our first meeting. Sharon had five children from a previous relations.h.i.+p and Alfie was the first child of her current marriage. She said her husband had wanted her to come and see me because he was worried about her. He felt that it was time now for them to put away the clothes that she had prepared for Alfie and to dismantle the crib that was in their bedroom. Sharon said she didn't really want to argue with him but she still felt the need to go and sit next to the crib and look at the clothes and think about Alfie.

Sharon did take a long time to come to terms with her loss. She felt unable to move on and come to terms with what had happened partly because she was troubled by terrible feelings of guilt. These feelings related to having missed some of her ante-natal appointments with the midwife. Also Sharon's family had disapproved of her choice of her husband and had warned her that marrying someone of a different culture wasn't 'right'. Sharon felt that for these reasons the outside 106 world would blame her for the loss of the baby. It was easier to imagine what it would have been like if Alfie had lived rather than face her own anger with herself and others.

Moving on from loss For most parents who have lost a baby, embarking upon another pregnancy will prove an anxious time. There is probably no 'right time' to consider another pregnancy since this very much depends not just on grieving and physical recovery but on all the other factors that go into deciding when is the right time to have a baby. Often in a subsequent pregnancy there is an emotional detachment from the pregnancy: an unwillingness to invest emotionally and risk experiencing the intense feelings of loss again. There is some suggestion too that the children born following a loss can have more physical or emotional difficulties due to over-anxious or over-protective parenting. It is probably important therefore to be prepared for the possibility of problems so that you are more ready to face them should they arise.

Who can help ?

During your labour and birth you will come into contact with a wide range of professionals especially if you have a hospital birth. However, your starting point is your GP and the local midwife who should be able to advise you about local services.Visit your maternity hospital and do the ward 'tour', where you can ask questions, see the labour ward facilities and the post-natal ward set-up. Find out about local ante-natal or parenting cla.s.ses from your midwife as here you will be given in-depth information about questions such as 'what is an epidural' or 'when should I go into hospital?'.

If you are seeking help with questions following your labour or struggling to come to terms with the loss of a baby, then both your GP and midwife should be able to answer questions about what happened and why. Following the loss of a baby, the consultant obstetrician will usually discuss the details of what happened or any information from the post-mortem.

When recovering from loss, the support of family and friends can be very important. At some point in time you may wish to speak to a Discussion points 107.

bereavement counsellor and your GP or midwife may be able to advise.

Not everyone wants or needs this type of help after a loss. For some people it is months or years later that they decide their grieving is 'stuck' or going on for too long. It may be another pregnancy that makes someone feel that they have issues to resolve and that they need to talk to someone.

On p.181there is a list of addresses of organisations that support parents who have lost a baby. This type of support, from others parents who have been through similar experiences, can be very helpful.

Discussion points This chapter raises numerous issues in terms of thinking about where and how you might like to have your baby and how you will manage the experience of labour. It might be useful to discuss some of the following points: 1. Where would you like to have your baby and what types of facilities would you like available? What is available locally? From where/whom can you get more information?

2. What preparations do you need to make? What ante-natal cla.s.ses are available?

3. Who should/will be able to attend?

4. What do you know already about different types of pain relief and what appeals to you? What helps you to relax? Do you have any experience of dealing with pain and, if so, how did you cope?

5. Who is around to help? Who will be your birth partner? Who can help out in those first few days? What specific help will you want: someone to do some shopping? A relative to stay at the house? Or would you prefer not to have visitors?

6.The first few days.

Your baby arrives at last !

It is impossible to describe those first few moments after your baby is born since the experience is so unique and personal. For the majority of women their first meeting with the baby will be as it arrives into their arms as soon as it has been delivered. It can be a moment of elation, of enormous relief and great joy. That is not to say that it is universally a pleasurable experience since many couples may be feeling so overwhelmed or exhausted that they hardly know what to think. Should your baby be unwell or born very early, there may be no relief at all as medical a.s.sessment gets underway and the baby is taken from your arms. These few moments are particularly precious since it is a time to meet this new person before other events take over: the initial a.s.sessment of the baby, the need for special care, the delivery of the placenta, the need for st.i.tches and all the other immediate and more medical concerns.

Going through your labour may have been an intense and exhausting experience both physically and emotionally. Had you just run a marathon, you would now expect to put your feet up and have a well-deserved rest, however, labour is just the first lap of an incredibly long journey.Whatever way the baby arrived, however exhausted and physically ill you might be, the task of parenting begins immediately. You will experience from the start, at its most intense, the dilemma that is central to parenting: the balancing of your own needs versus that of the baby's. This factor seems central to what makes the first few days such an intense and at times difficult experience and why almost all mothers will struggle emotionally at times in the first few days.

110.

In this chapter we will look at what might happen in those first few days.

What are the immediate tasks of parenting: how often should I feed the baby? How long will he sleep for? Should I pick him up when he cries? Is this something that we learn or that comes instinctively? Second, the mother has to recover from the labour. You may have st.i.tches, a catheter, bruising and discomfort and most likely you will feel exhausted. There can be a roller coaster of emotions too. Most women initially are on something of a high: they are immensely relieved the baby has arrived and appears well, the pains and emotions of labour have disappeared and they are sharing those first few moments with their baby. This, however, can very suddenly be replaced by tears, frustration and uncertainty as the reality of caring for the baby dawns and your tiredness and discomfort kick in.We will consider the emotional situation of those first few days looking at the range of reactions such as'baby blues'through to the serious but rare problem of puerperal psychosis. What is the significance of these emotional reactions and will they have long-term effects? How does an attachment develop between parents and their baby?

A time of intense and rapid adjustment Often books on pregnancy seem to trail off after the sections on childbirth and perhaps many parents-to-be are not interested in reading much further during pregnancy. However, it does seem important to emphasise that the emotional experience of those first few days may be very intense.

The labour and the birth of the baby are an important part of the transition to parenthood but only a part. A time of high emotion and rapid adjustment continues in those first few days. It would be wrong, however, to give the impression that this is necessarily a negative experience.The difficulties are almost always outweighed by the joys. What is remarkable is to see a woman who, in labour, was feeling intensely distressed, half-an-hour after the baby is born sitting contentedly holding the baby as if she had been doing it for years. Two hours later the same woman may be in tears at her struggle to 'latch the baby on' to the breast. The first few days are about all of these conflicting feelings, emotions and experiences.You are nowlearning your new roles of mother and father. First, let's think about the baby.

Forming a relations.h.i.+p with your new baby During labour it is possible to lose sight of fact that there is a baby arriving at the end. You may feel so caught up in dealing with the contractions or Forming a relations.h.i.+p with your new baby 111.

feel numbed by the effects of drugs that you may feel you just want to recover but the baby is thrust upon you, often literally. Suddenly you have a totally dependent and needy baby whom you must learn to care for.

Your first few moments with the baby New mothers spend an enormous amount of time just looking at, holding and exploring their new baby. Parents quite spontaneously look in great detail at this new person trying to get to know him and beginning to respond to him.The baby's tiny movements, expressions and vocalisations promote a response in the baby's parents and the very rudiments of communication begin here. Parents quite spontaneously start to respond to the baby: he is not simply held in a completely static way. The psychoa.n.a.lyst and paediatrician, Donald Winnicott emphasised the importance of not interfering with this process which happens naturally and spontaneously. It is not something that parents need to be taught. If you watch a new mother shewill spontaneouslychangethe baby's position in response to his movements. She will often move her head or face in a similar way to the baby, especially if the baby is awake and alert. If he begins to cry, she will attempt to soothe him, perhaps by rocking or beginning to feed. This clearly is a learning process, the parent does not know what to do yet, but the curiosity and eagerness to learn seem almost instinctive.

Mothers will often be encouraged to feed the baby if he is awake and both seem relaxed. The baby may of course be sleepy (especially where there has been use of medication during labour) and therefore you may just watch him sleeping. For many new parents this is a wonderful time of elation, of feeling closer to each other as a couple and feeling enormous relief at the baby's arrival. However, it isn't always so, depending on how you are feeling at this point: exhausted, overwhelmed, confused, and so on. The bond with your baby is not always instant and in many ways you are strangers who need to get to know each other. Not everyone feels that connectedness straightaway, it can take much longer but that doesn't mean it won't develop. Unfortunately the hospital setting may not always facilitate this process. Staff may not be available to help or may be preoccupied with different concerns.

The initial a.s.sessment of the baby Very soon after holding your baby the medical staff will wish to check the baby is well and complete an Apgar score (see The Pregnancy Book for an explanation of the Apgar score), clip the umbilical cord, clean the baby and 112 put on an ident.i.ty tag. Most of this may happen while you are delivering the placenta, being prepared for st.i.tches or whatever medical procedures are necessary for you.

What can newborn babies do?

In recent years as research techniques have improved we have become much more aware of the capabilities of newborn babies.We have known for a long time that babies are born with primitive reflexes. Clearly the sucking and rooting reflexes are crucial to a baby's survival. If you stroke a baby's cheek he will turn his head and start to suck. Babies can hear from birth but remarkably they quite quickly learn to recognise their mother's voice from others. They are able to focus on objects at a certain distance, this distance being roughly that between them and their mother's face during feeding. Quite quickly too they are able to discriminate their mother's face from others. It is perhaps important to remember when you are finding it a struggle, that your baby is primed to get what he needs i.e. to feed and also to develop a relations.h.i.+p with you. So he will be helping out too: babies appear almost programmed to develop relations.h.i.+ps. Most of their early behaviour ^ crying, making eye contact, vocalising or smiling ^ is all designed to engage the parent and form an attachment.

Getting to know your new baby: bonding/attachment Often when professionals use words like'bonding' parents feel intimidated as if this were something complicated and technical but really we are talking about you and the baby getting to know each other and feeling a closeness or connectedness. Many parents will say that they did not feel an immediate bond with their child and for some it may take many months to have that strength of feeling. The development of an attachment between parent and baby is important as this relations.h.i.+p provides the secure base from which the baby can go on to develop and explore his world. He does this secure in the knowledge that usually if he feels hungry or upset, his cries will bring the intervention of his mother or caregiver to provide the necessary comfort and security.