Thursday, March 03, 2005

My First Cesarean

Frankfurt, Germany - mid-late 1986

A woman found me via LLL (I was a leader back then) and asked me to be her labor assistant (no such word as "doula" back then). She was, after research, going to deliver in a German birth center. She did not, under any circumstances, want to have her baby in the military hospital (Frankfurt Army Regional Medical Center [FARMC] - it no longer exists). I don't remember if we talked about the what-if's... I know that I do now - but I remember being extremely excited about doing a birth out of a hospital in a foreign country.

We toured the birth center and met the midwives, who spoke minimal English. I loved the space. The rooms were so pretty - a garden yard could be accessed through the back doors of each room - and we moved through the space "seeing" my client in labor and knowing how great it was all going to be.

Labor time came and I met them at the birth center... mom was 6 cm dilated. (Isn't it amazing I can remember all these details? I had journals, but in a huff, my former husband threw them all out. My remembering birth details is in lieu of remembering songs - songs are lost in my head; birth details are retained forever!) Labor progressed really beautifully and mom spent a lot of time in the big bath they had in the room. It was cold outside, rainy, as usual, but warm inside and the steam from the warm bath made everything damp and soft.

Minimal vaginal exams were done, but mom asked for another several hours after one exam showed she was 8cm. When the midwife said she was still 8cm, the mom began to cry. As the midwife remained inside the mom, looking up at the ceiling (as midwives tend to do to be able to "see" with their fingers), I could tell she felt something besides the cervix and the baby's head. When she removed her hand, she began telling my couple, in her broken English, that she felt the baby's face presenting, which could hinder the cervical dilation. Through the years, I have studied face presentations and all-to-often, face presentations don't allow for enough pressure to dilate the cervix effectively. If given lots of time, it can happen, of course, but not everyone wants to wait that long.

And, the baby's head has to be in a posterior position to delivery vaginally, complicating the pain aspect of the woman's longer labor. If the baby is anterior, the neck cannot move that way through the pelvis without extensive damage. (For midwives and midwifery students, the mentum/chin needs to be anterior, which makes the head posterior - I've played with a lot of dolls and pelvises to be able to visualize this one. Researching, it is harder to find where the head needs to be since the usual discussion is regarding the mentum, not the cephalic presentation itself.)

The midwife said she wanted a second opinion from the doctor and when he came downstairs and examined mom, he said he could only feel an eyebrow, not a nose or eyes as the midwife said she could. He told mom she was fine and could keep going, even though she had been at 8cm for at least 6 hours with fabulously strong contractions.

When he left the room, the midwife sat there with a funny look on her face. My client was laboring, but I said to the midwife, "what do you think?" and she said, "I feel a complete face." My wonderfully strong laboring mom asked me who I believed. I said, without hesitation, "the midwife" because I knew that she had felt FAR more normal presentations than the doc and that if something was different, she would totally know. Mom asked for another exam before we began discussing alternatives and the midwife said she could clearly make out the mouth, nose, and one eye. Discussion began.

We talked about options. Augmentation with pitocin and cesarean were the two options we didn't have at our disposal at the center. Mom cried a lot during the talk, but she was an active part of the decision making.

As much as she did not want to go to the military hospital, she REALLY did not want to go to a krankenhaus, a German hospital. Not knowing if someone was going to speak English, knowing that a mediolateral episiotomy was SOP, that general anesthesia was SOP for cesareans... those options seemed worse than dealing with the military shit she had tried so hard to avoid.

I had been working at FARMC as a labor assistant for about 9 months by then. The nurses and docs all let me in - some tolerating me, others welcoming me - and I knew them all and knew most of their styles and personalities. During my time at FARMC, L&D was in two different parts of the hospital due to reconstruction. I had my baby when the hospital was on the lower portion of the hospital, right at the ramp to the parking lot. When Sarah had her baby, Aimee (my car baby) was 3 months old. The maternal death I witnessed was when L&D was up on another floor. In remembering, I thought that happened in 1986, but it might have happened in early 1987, but most likely late 1986. I wish there was someone around to ask so I could piece the time together. I know this is pretty irrelevant to readers, but for me, it helps me put the time frame together. When remembering being a doula back then, the births are distinctly divided between floors. It's good for me to write that down.

When it became apparent that a transfer would be needed, I called FARMC to find out who was on and to give them report. Blessedly, blessedly, the doc that was on was my favorite... very loving and kind... just the kindest doc at the hospital (the doc that caught Aimee and did my abdominal surgery was my second fave - fave for surgery, but not for birth). The head nurse was my favorite nurse Sally who was pregnant with twins and, years later, she became a CNM in the deep south (USA). When I was able to reassure my client of the kindness that would meet her, it made the transition so much easier. On the phone, Sally said it would depend on what was going on, but that an automatic cesarean wasn't what they would do. That also helped.

We drove our own cars to the hospital and the move into the labor room was typical with the changing of the clothes, the bracelet, the IV, etc. All stuff mom didn't want, but knew she would be getting simply by stepping inside their doors. Once the doc came in and examined her - she was still 8cm and it had been at least another 4 hours since the first 8cm observation - he said the baby was posterior, the ideal position for a face presentation birth. He said he had done face births and didn't have a problem at all with her continuing. Mom was relieved! He offered pain meds; mom declined. He offered pitocin; mom declined.

She labored for 4 hours and had another VE. 8cm. The doc said that he really thought she would need some pit to put enough pressure down on that cervix to get it open enough. Mom declined, but also said she couldn't do any more. She'd been 8cm, with 8cm-type contractions, for about 14 hours.

Discussion of a cesarean began. No one was harried. No one was mean. Everything was explained quietly and respectfully and mom, even as she cried, she was able to verbalize her desires for remaining close to her baby, staying awake, nursing soon, etc. The hospital said they would do their absolute best to adhere to her wishes. I believed them.

I hadn't ever been to a cesarean birth before. While I was disappointed for my mama, and damn tired from standing for so long (I weighed about 280 at the time), and am sure my boobs were going to explode from not nursing for so long, I was also excited to get into an OR. Oh, yeah, they were letting me in!

Sally asked me if I knew how to behave in an OR... would I get sick? I said I would not get sick, yes, I knew not to touch anything, to stay out of the way, etc. In reality, I knew nothing. laughing

Dad was in the room with mom as she answered a thousand pre-op questions. She'd asked me to stay to help with contractions, so I was privy to some information I hadn't known about. When mom was asked about how many times she had been pregnant, she said 3. Live children? none. Spontaneous Abortions? None. Therapeudic Abortions? Two. I didn't think anything of it, because that's how I am.

Mom was taken back to the OR to get the epidural before dad and I were brought in.

I was given scrubs and had to ask for bigger ones three times. I ended up in XXL men's gowns (one forward/one backward), only undies underneath (I didn't know to keep my clothes on back then). I put on the shoe covers and the head covering thingie. And I waited with my camera.

I was in the labor room waiting with dad and he was really quiet. I asked, in my labor assisting way, if he was okay... that this was quite different than they had planned for. And he looked up and said, "she never told me about the abortions." Oh, my. I gently said that he might wait a few weeks to talk about that, how hard that must of been for her to share in public and in front of you and she was birthing his baby in a few minutes... and I hugged him, letting him know it must have been hard information to hear.

This taught me to let women know, at any time I have a second of a private moment with them, that if they have stuff to share that their family doesn't know about, to ask everyone to leave and only speak with the nurse alone. I also, in interviews, tell them that if they ever want to speak without me in the room, too, just say it! I take no offense whatsoever.

As I was putting my OR suit on, I made sure my hair still looked good. I had a perm at the time and I floofed my air as a halo around the edges of the elastic paper cap. I looked good.

We were escorted to the OR where mom was already splayed out cesarean-style and Sally walked up to me and grabbed my head thingie and shoved my hair under the cap totally. I'm sure I gave a little whine and she stood back and glared at me: this is surgery, not a beauty pageant. I clamped my whine shut. I knew I would have bad hat head, but pushed it out of my mind.

I'd never had a mask on before. I remember that I felt lightheaded the first dozen or so times I wore one until someone explained to me to JUST BREATHE NORMALLY! What a concept, eh? I don't quite know how I was breathing, but it wasn't normally. Plus, the way I was breathing, my glasses kept getting fogged up. Years later, someone showed me the trick of pinching off the nose clip so the air doesn't zoom up to the glasses. For this birth, however, I was breathing funny, felt lightheaded, had foggy glasses, and worrying about my hat head.

Dad was plopped down on the head stool, but I was allowed to wander around the OR to take pics. (Something that would never be allowed nowadays.) As her belly was being opened, I smelled that burning flesh odor I'd never smelled before - and immediately thought of the smell of the Holocaust, feeling all light-headed again. I faked it, though, and forced myself to chill and Be in the room with my client.

I saw the uterus and it was so beautiful! I leaned forward to snap a picture and Sally, my OR shadow, snipped the cord of my camera right off the camera! I pulled back and looked at her confused-like and she looked at me (the only thing on her face that was visible were her eyes) and said, behind her mask that I was about to lean over onto the instrument table and my camera strap would have contaminated everything on there. I blushed.

Stepping over the now-dead-on-the-floor camera strap, I carefully took pictures as the cesarean unfolded. I became much more aware of my space and place in the small OR.

My client, awake and excited, yet crying at times, listened as her baby was born in a loving and respectful manner. I am eternally grateful that my first cesarean experience was so positive and gentle.

Her son, weighing 9 pounds 12 ounces, came out and for two weeks after birth, held his head as if he was watching angels near the ceiling; the back of his head touched his spine.

During mom's physical recovery, she thought lots. She wrote me the most beautiful card, many words shared, about how, in a place she'd dreaded spending time in, she'd found that she could trust even those she'd never trusted before. She said the lesson of putting your life, or the life of your child, into the hands of strangers and trusting them to care for you was the hardest thing she'd ever done. She said she learned a lot about trust and belief.

I learned, too, that women can have decent experiences in the hospital. Of course, over the years I have seen the worst of the worst and the best of the best, but, when medical care is needed, it CAN be decent. Should be, yes, that's a given. I have worked hard to know how to make it decent over these years. Most times I succeed. Sometimes, it is absolutely out of my control.

4 years later, mom was in the US in the northeast and had found a birth center to deliver in. She was strong in her desire for a VBAC and I knew she could do it. We talked during her labor, sometimes 2 hours at a time, and when she hung up the last time in her labor, she was pushing her baby out of her body. Her VBAC was a triumph for her! As VBAC is for all of us, even those of us who've never had a cesarean at all.

Tuesday, March 01, 2005

H2o HBAC!

So, a woman called the midwife I work with most of all… the same midwife I took to the Hand's-Off birth several months ago… because her OB was telling her stupid stuff about wanting a VBAC, something he’d promised her the entire pregnancy. She was then 34 weeks along.

Her first birth was in Australia and for a variety of odd reasons, she was induced at 36 weeks along. When that failed, she had a cesarean.

This time, in the US, her hand-picked doc said, “oh, yeah! VBAC? No problem.” At 34 weeks, she brought her birth plan in and he rolled his eyes, trying to be somewhat discreet, but then went on to say things like, “your uterus might explode during pushing,” and, “we just don’t want to meet in a courtroom with you showing a picture of your dead baby.”

She left horrified and that is when she remembered her former childbirth educator turned midwife and called her. She came to see us the day after that appointment, but on the way to my office, she picked up her records.

In my office, we’d just had our conference committee meeting, so Tonya Jamois, the president of ICAN, another doula, the midwife and I were all available to share with her… and we did. The woman and her mom sat on the couch in my office and showed us her records. The last note said something like: Reviewed birth plan. Consider general anesthesia for repeat cesarean. She was stunned that he would put something like that… and she would never have known had she not gotten her records. She would have gone in for a VBAC, been railroaded into a cesarean, and had general anesthesia to boot.

Thank god she woke up.

So, at 35 weeks, she decides she is leaving the doc and choosing to have a homebirth… something she had not ever considered. Her husband needed one meeting with us and he was convinced.

Because her previous birth had come at 36 weeks, this full-term pregnancy was forever-long. She kept saying how she wanted to have the baby and we chuckled, telling her we would remind her of this moment in the throes of labor. And, as all women do, she went into labor… 40 weeks and one day.

I got the call to come over at about 7am and got there at 8:30 or so… damn that San Diego traffic.

Mom sang her heart out during contractions. Her sister was there, her husband, and the right-before-pre-school twins. The day was sunny… the first one in at least two weeks. A lovely morning, in a beautiful home overlooking hills and mountains in northern San Diego County.

The pool was filling up and mom moved around, waiting to climb into the water. Once she got in, she didn’t get out again. From side to side, to hands and knees, she felt SO much better in the pool than out. Her sister clung to the mom’s hands for awhile, but the kids needed attention and mom wanted hands to clutch; I became the clutcher.

Along the way, dad got into the pool with mom. He was so calm and loving and gentle. He was great.

The sister was interesting though. She’d had two hospital births and wasn’t quite sure where she needed to be or do. She massaged her sister hard, like she was getting her warm after she’d been in the snow for a day and a half. And at one point, her “relax, relax, relax, relax, relax, relax, etc.” needed calming, so I gently said, “please don’t use that word” and she stopped saying it.

Nearer the end of the labor, I needed to move from the hand-holding so I could ready stuff for the birth (it was all in the bedroom; we were in the living room) and sister took over again. I came close at one point and the sister grabbed my arm and looked me in the eye and said, “I’m scared” and I sat next to her for a second and told her how perfect everything was, how wonderful it was all going… and the moment she could, she excused herself from the handholding and asked me to take over.

I held mama’s hand as she puuuuuuushed. She never held her breath and wasn’t even sure she was in second stage.

She asked for a vaginal exam a couple of times, but her midwife was able to deflect. It was great! She would ask, “where do you think I am?” and her midwife would say, “where are you?” She would ask, “can you check me?” and her midwife would say, “you can feel… where is the baby?” and it always worked! The only time the midwife checked was after imploring (mom’s) and the baby was a knuckle inside the vagina; no cervical checks at all. Listening to fetal heart tones was very occasional.

We did our best to honor the marriage bond, the mother’s desires, and remain just under the radar. Unless asked.

So, mom is pushing… grunting with all her voice… and from above our heads, her sister says, “put your chin on your chest!” and I nearly busted out laughing. The midwife and I looked at each other and the midwife repeated that she was pushing exactly how she needed to, that the baby was advancing perfectly… and sister didn’t say anything else about how to push.

For days after the birth, I could hear those words – put your chin on your chest – and it made me laugh out loud, several times. It was hysterical and sad all at the same time, how indoctrinated every woman (almost) is in the American Way of Birth. Blessedly, there were enough of us around to counter the brainwashing. I wondered about my own gradual un-brainwashing… and its continual evolution.

Mom loudly sang her wonderful 9 pound baby girl out in the water over an intact perineum. Her uterus did not explode in second stage.

As the baby came out, they were giddy with joy. “I did it! I did it!!” and mom and dad, embracing their daughter, cried in words and tears.

Blood began oozing out into the clear water. The water began getting murkier and dad was a tad concerned, so mom stood up, stepped out of the pool and delivered the placenta into the bowl.

She walked to the toilet, dried off, and then climbed into the bed with her family and nursed her big ol’ girl for hours.

We did the three day home visit yesterday and talked and laughed and cried about the birth. The tears came from hormones and her observations of her Self during her birth. She spoke of her sheer joy that we never took her power, even when she offered it. That we were so respectful and careful to keep her in her power… how we encouraged her to believe in her own knowledge, to know that she could feel her own body. She spoke of her own pride, over and over, and that made the midwife and I so proud, so filled with joy that we, too, wept.

Mom told us we changed her life. Dad said he has now become a crusader for homebirth and has told everyone at the office they should consider it, how joyous it was. We told them both that they, too, affect our lives, that their joy, their power, their belief in their Truths, reminds us of what we are doing this for.

The most tender moment of yesterday came when she took my hand and looked at me and told me that one of her highlighted moments in her labor was when she needed help and opened her eyes and looked at my smile and my bright blue eyes and felt safe and could go on. It means so much to me that I can remind a woman of her perfection in those moments of challenge and, even sometimes, fear.

What a joy this birth was!

And her uterus, her vagina, her family, her nursing relationship, her psyche, and her spirit… all remain whole and intact.