Monday, December 25, 2006

December Birth # 3

Mom called me and told me things were starting and I called my assistant and asked her to come to my office, half way to the mom's house from hers, and and sent my apprentice home to take a nap and asked her to come back a few hours later and we waited. And waited.

Those who have read here for any length of time know that if I stay the night at my office, the woman's labor will surely peter out and I will have spent the night for nothing, but if I go home to do anything, her labor will speed into overdrive and I will have to pick my head off the pillow and drive back half-asleep. Weighing what to do is one of my biggest challenges when a woman isn't in full active labor.

We sat on my princess bed (well, two of us did, my pregnant apprentice sat on the camel chair) and talked as the afternoon darkened the room and we giggled and yacked about all things midwifery and relationship. How can three women talk so much about birth?! We ask ourselves that everytime we see each other. Do we ever get bored? Never! It is so nice to finally have someone with whom to talk incessently to. Finally. Our families sigh with overwhelming relief.

Dinner time comes and mom feels contractrations are about the same-only-less, so says we should go home and she'll call me in the middle of the night. I sat there on my triangle point trying to figure out which side to go down... stay at the office (20 miles from her house) or go home (55 miles from her house). The girls tried to help, but they were as undecided as I was.

We decide to go to On the Border. You see, On the Border is our restaurant of choice when a woman is in piddly labor that is sure to kick into high gear as soon as we are served 1) drinks 2) dinner. This has happened no less than three times and we laugh that we need to go there when we are in that odd place trying to figure out if we should stay with a mom or go home... "Where's there an On the Border?"

My apprentice lives kind of on the way home, right by the On the Border, and the other lives past where I live. After dinner (where we didn't hear from the mom at all), I took them home with me thinking she was surely going to call, but, once there, she called and said she was going to bed. Each woman called a family member to come and retrieve her from my house. I went to bed the moment they left.

About 2 hours later, the dad called and said things had picked back up and we should think about coming now. It was 10:30pm. I called the girls and got myself together and drove to pick each of them up (neither of whom had slept) and got to the mom's house about 12:30am.

Labor was ineresting. When we talked on the phone, mom said her contractions were every 5 minutes lasting a minute or so, but they were much shorter than that upon observation... maybe 20 seconds. She had to concentrate for a very short time when she had contractions. This was her second baby, but she'd had an epidural and pitocin for the first, so it is, for many women, almost a primip birth. My apprentice and assistant set things up while I assessed the contractions and figured we had a long night and day ahead of us.

Mom was in good spirits and dad was very excited. Their daughter, still nursing, was sleeping. She didn't have an in-depth relationship with dad, so mom had to tend to her when she would awaken. Dad did a great job trying, but mom, in the end, had to go and nurse her back to sleep. We wondered if this affected her labor progress. I believe it probably did.

There were a couple of requests from mom and dad: dad did not want to catch the baby and mom wanted the baby cleaned off before being handed the baby. Not mine to question, just mine to follow.

During the pregnancy, the daughter took a serious liking to my apprentice. I mean, such a liking that she (the daughter) thought I was the assistant and my apprentice was the midwife (it was a great opportunity for her to take a very active role as the lead midwife)! Pretty early on in the care, I'd decided that this would be my apprentice's first catch and a couple of month's ago, let her know it would be. She was demure and sweet and said such kind things like, "This isn't about me, it's about the mom and baby." I would have been all giddy and happy about my first catch, but she wasn't and I thought it was interestingly odd, but shrugged and thought it was just her quieter style. I tend to be more noisy. Surprising, I know.

I needed to sleep, so the "head midwife" spent the night awake with the mom and dad as I slept on the couch a few feet from them. The assistant slept in an adjacent room (where the birth was going to occur... not the bedroom, where the toddler was sleeping). Every once in awhile, I could hear snippets of conversation and got a gist of the contractions... short and sweet... not moaning... I kept thinking, "oh, yeah... plenty of time still ahead!"

About 4:30am, the toddler awoke and dad tried to quiet her, but once that wasn't going to happen, mom nearly jogged to tend to her. I blinked my surprise at her laboring agility and made a mental note of "where would a woman have to be in labor to jog to her child to nurse her?" The dad, who'd given a valient effort, seemed sad that he'd failed.

The apprentice went to bed, the toddler got up, I went to doze on the couch, and the mom went back to laboring in front of the fireplace.

She'd been having some mean posterior-type contractions earlier, so we showed her hands and knees and that position seemed to help. She remained on hands and knees for a few hours and the back pain seemed to subside compared to what it had been earlier when we'd arrived.

I laid on the couch, half-awake, listening to the family interacting - mom eating oranges, drinking juice (she did not like water very much at all, but would drink ice water occasionally) and counting contractions. They were so far apart... and so short. I was sure we were still in such early labor, we could go home for awhile, or at least get out and eat and have some time in a bed before returning.

As dawn broke, I awoke and sat with the mom who pulled in tightly as I talked with her about her contractions being far and short and how they seemed to be in early labor and not as long as she described them. She said that when I wasn't there, they were longer and I said that I believed her! I said that happens often and that perhaps we all needed to go so she could find her rhythm once again and then she could call us when she was about ready to have the baby. I told her I just thought she was still early and would have so much time based on the ebb and flow of the contractions. I offered to do an exam, but knew she would say no because she had expressed no desire for any exams the entire pregnancy and when I needed to do one to determine a head or a butt a couple of weeks earlier, she was less than pleased.

When I woke the apprentice and assistant, we also helped the dad and daughter get ready to go to the store for awhile to allow mom to rest. Her contractions had completely stopped by this point and she was suddenly extremely tired and wanted to go to bed. I thought it was great for us all to give her some time to sleep so she could wake up in labor.

When we drove away, we talked about mom's possible inability to focus on labor with the toddler there - how she literally jumped to her needs and how we thought it was good she was going out of the house, too, for awhile. I thought it was good for all of us to head out for awhile.

We drove down, in morning traffic, to where the On the Border is (45 minutes away), but went to IHOP. We were tired, but talking about the upcoming birth and how nice it will be, how we thought it would be at dusk (we usually see births shift at dawn or dusk) and waited for our food while we sipped our iced tea and coffees.

Mom called and said she was having a feeling like she had to pee every few minutes, like with the contractions, was that normal? I said, "Sure," that she might feel it lying on one side more than another and if her bladder is full. She said she was still resting. We still waited for our food. What was taking so long?

Just as our food was being set down (and damn we were hungry), mom calls and tells me she feels something in her vagina... a bag or something... and immediately I know, the baby is coming - and I won't be there.

The girls hear nothing coming from me, but see my face and I begin digging in my wallet for money and I throw $40 at the assistant and begin slowing and calmly talking to the mom about what she is feeling so I can talk her through this. She is alone.

My thoughts that fly through my head in one flash:

You ass! She's alone. Get her husband back home. Call her husband's cell. Her daughter's gonna freak. Call 911. Offer to call 911. DON'T CALL 911!! Please don't want me to call 911. Stay calm. Please don't be breech. You can do this (the mom). Slow and calm (me). Why am I so fucking far?! I will never make it. Why is it morning traffic time?

And probably a lot more expletives I conveniently forgot.

As the assistant pays, I remember getting into the car, me driving, and telling mom how to stay calm and how to deliver her own baby, that is, by the way, in the caul. I tell the apprentice to call the dad - mom has to repeat his cell phone number about 10 times - and tell him to go home NOW - and that's all he hears and hangs up on her. She calls him back and tells him if he goes in the house and finds a baby, to please put a blanket on the baby, which further freaks him out.

I stay on the phone with mom, talking to her gently throughout while careening through rush hour traffic (sorry everyone) and she moves from the toilet to the bedroom where she wants to deliver and gets on her hands and knees. I reminded her that she knew how to do this instinctively, that she had the power... anything to keep the banter going. I told her I had to offer to her to call 911, but that I believed in her and I knew she could do this alone if she wanted to and that we were calling her husband back to her. I had to let her know I wouldn't make it to the birth, but I wouldn't leave her on the phone.

Dad gets home about 9 minutes after we call him and we talk him through the birth, which happens about 4 minutes after that. When dad got on the phone, I asked him to center and focus because he'd been out in the world and running and he needed to be centered to catch his child. He was fantastic as he took a breath and I could hear him audibly relax.

He kept asking what he should do and I stressed making sure the baby could breathe once the baby was born if the sac was still over the face. He said the sac was coming out and he could see the head was coming out... he was giving me the sizes in coin sizes, but I think they were European coin sizes. As more and more of the head was born, he started telling me the head was purple.

At one point, I thought he told me the baby was born and not breathing and I told him to take the sac off the face and rub the baby's back... I didn't hear her crying (they knew it was a girl)... and I was getting scared. Then he finally said only her face was out and looking at him, I relaxed and said she would come in a moment and as I said that, she was being born and cried right away.

I was thrilled. Can I say now that every pregnant woman should be required to have speaker phone?

They got blankets on her (I'd had him turn the heat on 80 as he ran in the door and turn the heating pads on) and then I told them all they had to do was just sit with each other and wait.

We arrive 19 minutes after the birth. 28 minutes to get about 45 miles in morning traffic - not too bad. Too late for the birth, but we made it for the placenta!

We came in (after calming before entering) and set to work assessing - all was well, but there was some bleeding we had to tend to. The placenta was born with some assistance, mom needed a shot of Pitocin, the baby's cord was cut (it had long stopped pulsating), and we cleaned mom and the bed up before righting the room and getting the things that we no longer needed out of there.

Mom was pretty stunned and it took a couple of days before she was happy with her birth experience. She is proud now, as is dad. Remember, he did not want to catch and she wanted the baby cleaned off before holding her; neither happened. But, he was promoted to midwife and she was the first to hold her child - both are very proud to have been alone when their baby was born. The daughter was scared and ran out of the room at the moment of birth, but she has acclimated to her sister just fine and is even finding a way around tandem nursing.

Amazing what we can do when we have to, isn't it?

So, my apprentice didn't get to catch and even when we were going to have her catch the placenta, that didn't work out either because of the bleeding, but she did get to cut the cord and did that very well (it was her first time). She told me that throughout the pregnancy, she just didn't see herself catching this baby. She'd said that she couldn't even picture the actual birth itself, which none of us could either (and that was odd), but now we know why! I still don't think she'll be as giddy as I was anticipating my first catch, but perhaps she'll be able to visualize it.

Oh, and one final note: Postpartum, I looked over at the bookshelf in the room where the baby was born and what was there but Anne of Green Gables. I laughed and we wondered aloud how many births Anne has witnessed! We know of at least two in a row this December of 2006.

Thursday, December 21, 2006

December Birth #2 - Birth Brought Ailie

Mom had UC'd with her third birth - her first two were in the hospital, the second a total, fabulous precip - all under 4 hours. With this birth, she wanted something different - a different energy - something she wasn't able to completely describe to me, but conveyed to me by hiring a midwife (me) who would play by her rules as long as things were safe and all was wonderful and cool. And all was wonderful and cool, indeed.

During the pregnancy, she agreed to allowing me to draw a prenatal blood panel and listen to the baby's heart rate. Blood pressure and measuring the uterus are not the most crucial things for me, but she allowed us to do those, so we did. All was fine and dandy.

Our biggest obstacle was getting to mom's house before the birth (she lives far from my office and even further from my house) and extensive counseling was done regarding staying close to the ground and not being on the toilet if she was alone during the moment of birth. Mom really felt we would make it this birth and the assistant and my apprentice also felt we would, but I wasn't so sure. I just wanted all the bases covered, so made sure she knew: low to the ground and off the toilet!

She knew labor was going to come soon by contractions that were annoying, but they stopped periodically over the few days before they wouldn't actually stop. Once the didn't totally stop, she still could sleep through them for some of the night, but she walked and wandered and puttered around the new house to keep her mind off the contractions and on other things.

Her best friend, another client of mine - the client of mine that transferred to the hospital and then subsequently hemorrhaged at the birth - spent the day at her house entertaining the two younger kids, feeding and watering her (the laboring mom) and taking cool pictures of her fixing the heater (with tools and everything). The two dads also hung out that day playing poker for some sort of yogurt balls (I'm sure someone will understand what I am talking about) and then when it got closer to dark, the laboring mama thought it was cool to have us mosie over - not that anything had changed, mind you. She'd been in labor for about 17 hours by this time - a new record for her. Her total labor was 21 hours. We were there for about 90 minutes before the birth.

I gathered the troops (I drive them to births when we have time... it's a nice trip back and forth) and we headed up, wondering if we'd make it or not. When we got there, we saw our previous client holding a baby and wondered if it was hers or the new baby. It was her own. The new baby waited inside the mother for the midwife to come.

It was a hootin' party inside! Kids hollerin'. Dads laughing. The tv playing some sort of kid's cartoon. Something baking. How festive! Where was the labor going on?

Oh, there she is. In this side room over here.

We walked over to the room and there's mom hunched over a birth ball watching... what's this? Blinking, I had to laugh outloud.

I've experienced a whole lot of different styles of relaxing in labor. I've written often about how I own every Enya, but if I never had to hear her again in a labor, I would be thrilled. Between she and George Winston, they are my hands down faves for most over-played labor music, although hypnobirthing tapes are outweighing George nowadays.

I loved this mom after spending time getting to know her, long before I was ever her midwife, but what she chose to watch in labor sealed our fate as "kindred spirits."

Anne of Green Gables & Anne of Avonlea

Yes, it's true. She spent her labor watching the tales of Anne Shirley and Gilbert Blythe and life on Prince Edward Island, Canada.

Suddenly, I knew we could be lifelong friends if she could/was watching this movie in labor - in deep and heavy labor! A woman after my own heart.

We pulled in the supplies from the car, but most of them stayed in the living room or dining room and we brought in just the actual birth essentials (gloves, clamps, mirror, flashlight, etc.) and got the blankets warming on the CPR board (that we surround by two heating pads). We ended up taking one set of vitals and two sets of heart tones on the baby and that was it because all was fine - and things progressed quickly.

After the initial shuffling of bodies into the room, we got settled: I was on the bottom bunk with my apprentice, the assistant close to the tv, the mom on her ball or kneeling on her ball in the center of the room, the friend wandering in and out and the kids doing the same.

Eventually, the one dad left with the friend's kidlets and the youngest child of the house fell asleep so dad put her to bed.

Now, this dad wasn't going to have a part in this birth. We assumed it was cultural and it very well might have been, but it was also a pretty big assumption on our part. He'd left for the UC and mom had her friend (the same one that was here this time) there to catch and he came back when everything was cleaned up. That was the plan pretty much for this time, too, except this was nearing midnight and there wasn't anywhere to go with two sleepy kids. Near the end, he stayed in one of the back bedrooms (I think).

The saga of Anne continued as tension between her and Gibert rocked back and forth - much the same as my client on the ball, although she barely moved or breathed differently than you or I are doing even now. If you didn't know she was in labor, you might not have even been able to tell. She got up and waddled to the bathroom every few minutes - the most obvious strenuous part of labor looking at it from the outside.

Many women's contractions are regular and rhythmic, but this woman's were, down to the second, 5 minutes apart from when we arrived. When Diana Barry got married, her contractions moved down to 3 minutes apart and her breathing quickened slightly - eyes closed more time than opened - and we could see things were coming closer.

You know in poems and stories how Death is spoken about like a person or an actual being? How Death walks in the room or you can smell Death? (I hate having to talk about that like this in the middle of a birth story, but there is no other way to talk about this but this way.) Well, at this birth, Birth walked in the door.

Never, in all these years of working, have I ever, ever, ever experienced such a tangible moment of clarity that Birth was imminent without any outward signs to tell me so. There was no bloody show. There was no pushing. No contraction. No grunting. No sighing. No crying. No words from mom at all. There was one thing only.

Birth walked in the door with her arms filled with the scent of herself.

As if we'd been sitting in pitch black (no scent) and someone (Birth) turned on the lightswitch, the scent of birth was not there and then, just as suddenly, was so pervasive my head swam in the headiness of the scent of this woman's oceanic wetness that hadn't even spilt a drop anywhere outside of her vagina yet. I looked at the women around the room.

My apprentice, my assistant, the friend/my client - did I say outloud, "I smell birth"? or did I just say, "It's time to wash our hands"? Somewhere before or after washing my hands I sat on the floor and turned the tv off while the friend turned the video camera on and we hunkered down on the floor and watched as mom's amniotic sac burst against the back wall and she laughed thinking that was big fun. 4 minutes later the baby was born.

On hands and knees, mom let the baby come down and we watched as she came down somewhat acynclitically (thank goodness she was small!) and I encouraged mom to reach down for her baby and she got one hand down, but couldn't quite help her up so the assistant helped the baby out and up through her legs so she could bring her baby up to her own chest.

We brought warm blankets over to let mom dry the baby - no hat! (I have this thing about babies and hats, you know, and this mom didn't want a hat on her kid. At the home visit, I said that I really wanted a hat on the baby since it was going to be cold and she said, "that's nice" to me. I just laughed, knowing where I was going to go with any further hat discussion.)

Dad heard the baby's cry and walked by the room and said something like, "already?" and then something along the lines of "yuck" before walking away. We closed the door so we could get things cleaned before he had to see the baby again. Closing the door also made the room warmer.

I'd made a concession (my own) about the hat by bringing an extra space heater (I carry one in the winter anyway) into the room and we had it going along with their space heater. About 5 minutes after the birth, a fuse blew and there was suddenly NO heat in the room at all except by all of our body heat. I had to laugh at all my planning ahead. Someone tossed a big blanket on top of mom and baby and I hoped for the best. I was glad we weren't in Minnesota.

We cleaned things up as mom was fed and juiced and then she trekked to the toilet where she said she knew she tore. I asked if I could look and she said, "nope," and I said, "you won't let me suture if you tore where I could suture and make you more comfortable?" as she sat wincing her face all scrunchy on the toilet. "Nope," she said. Eek! Okay. breathe

We cleaned up the room, got the bed ready for her to climb into as the dad got the fuse thingie fixed. I checked over the baby really quickly (with mom's permission) while she was on the potty and took her temperature (she was a girl!) and it was a chilly 96.9. I expressed my concern about her temp and wrapped her up warmly and suggested a skin to skin and under the blankets once they were together again. I kept her close to me until mom got back.

We loaded our gear back into the car and headed out a lickity-split 90 minutes after the birth. Only one other time had I left that fast after a birth - after my now-apprentice's hands-off birth, It still felt bizarre. So much was left undone! I charted "mother refused" on the newborn exam, the vitals, the measurements, the postpartum instructions, the place where it asks if mom had a tear or not and whether she was sutured or not. So many things normally/typically done that just weren't done. I marvelled at my groove and how I squirmed stepping out of it. I'm sure it was a great lesson for me to experience. Couldn't have been with a better group of women, that's for sure.

So, after the birth, in the room, there was me, the mom and her new daughter, the friend/my client, my apprentice/client, my assistant, and the new mom's daughter and we were giggling and having a sweet time when the husband tried to get the older daughter to go to bed. There was way too much energy to get that to happen, though. I laughed thinking of all that chick energy zipping around in there and what an honor it was to be lathering ourselves in it... how very blessed we were to be invited into this woman's space where she opened her door and showed us the room where she let Birth walk in and set down, right on her lap, a beautiful baby with the middle name of "Anne."

December Birth #1

Mom had had a great birth experience at a local birth center for her last birth, but hated the car ride down there. She'd arrived at 8cm, pushed for 90 minutes and was there a mere 3 hours before the birth of her baby. She was going to birth in another birth center this time, but nearing the end of the pregnancy, her doula suggested a homebirth and she was off and running.

We met and I was one of three midwives she interviewed. Another midwife told her how horrible the birth center was she was that she was scheduled to birth at, how high their transfer rate was to the hospital, how high their cesarean rate was, how residents practiced on the unsuspecting women in the center... all untruths I corrected and told the woman I had worked many times as a doula and with transfered midwifery clients both in the birth center and the hospital and that she had a wonderful possibility of having the exact birth she wanted to have - including having her daughter jumping on the bed if she wanted her to. She was very relieved and said it was my lack of need to make the other guy seem evil to make myself seem angelic that was one of the things that sold her on choosing me. I told her I nothing to lose (or win) in telling the truth - my goal was for her to have the birth of her choice wherever and with whomever that might be.

She began co-care with me at 36 weeks of pregnancy.

She told the CNM she was seeing she was going to have a homebirth and didn't get a ration of shit (which was nice and doesn't always happen) and kept up her weekly appointments and then had one NST/BPP that went fine. She was scheduled for another BPP, but was debating going to that one - went into labor instead.

During her last labor, she had a doula that helped her so much. She said she was so motherly and kind, she really wanted her again and looked forward to having her join the team. I told her I would love to have her along. I knew the doula's name from the birth center - and had actually relieved her once during one of her long births - but we'd never really interacted before.

At the home visit, we did our usual routine of finding where things are, talking all about the birth, discussing expectations and doing a prenatal. My home visits tend to take about 2-3 hours. Way too long, probably, but that's the way it goes.

The doula was pretty quiet during the home visit, asking a question here and there, but nothing really dramatic.

During a prenatal visit, we knew there was a serious misunderstanding of what a homebirth midwife is and does when the question came from the doula via the client:

Will you allow the cord to stop pulsating before cutting it?

and

Can you wait to put the eye ointment in until the mother and baby have bonded?

I thought, "uh oh."

I called the doula after that prenatal visit, but she was out of town and wasn't able to call me back and the next time we spoke was at the birth.

Dad called me early in the morning after we'd gotten a full night's sleep and I went to pick up the assistant before heading over to mom's house. This client lives really close to me - an oddity in the clients I have - and it was nice I was still at home and not at work where I'd have been over an hour away.

Mom was in the tub, the doula was working with mom and dad was there, too. The young daughter was playing around the house aswe began setting up for the birth. Contractions were about 5 minutes apart. We didn't anticipate a very long labor since her last one hadn't been so long. Mom was communicative between contractions, but we could all tell she was sure working and concentrating on her work.

It was crowded in the bathroom, so dad took the door off and it was easier for us to be in there together, even though there wasn't much call for all of us to be in there at one time unless the birth was going to be in there. Later, it kind of sucked that there was no door because I had to go to the bathroom and there was nowhere to go for privacy. I thought about propping the door, but that wouldn't have been enough of the type of privacy I would have wanted. If you get my drift. And I think you do.

The dad off and on played with the four-year-old daughter who was very well-behaved. We'd talked prenatally about having someone there specifically for her, but they didn't ever do that, so she tended to talk to us and her dad. She was respectful of her mama's space and experience and we did explain things as we went along, but it would have been good to have someone there just for her, too.

Prenatally, mom let us know she wanted the doula to take a major supportive role and that was fine with us - we let her know we would stay out of the way and let the family do their thing and be there when they needed us. In retrospect, I should have been more clear - and will be in the future. The doula, it seems, sometimes felt the birth and birth space was hers to direct and it was frustrating. The mom never felt anything amiss in her birth (thank goodness), but between the doula and the midwifery team, there was a definite tension.

It was important to us to keep the tension from affecting the labor and birth, so removed ourselves where possible and allowed things to remain stable and calm without the odd rocking that came when more than three of us women were in the room at any one time.

An example: Mom asked that her hair be braided and the doula was brushing it and attempting to braid it. The mom also really needed her lower back pressed during contractions which was the main job of the doulas until she began braiding hair, so I send my apprentice in to press on mom's back until the hair braiding was completed. The apprentice came out and looked at me saying she wasn't needed and I went in and saw that the braiding was abandoned and the back pressing resumed by the doula - a territorial movement that was so unnecessary, but one that was repeated until we figured out what was going on and ended the game mid-action by not playing anymore. Just by acknowledging what she was doing, we were able to not get in the middle of it.

The labor was beautiful. It unfolded so gently and peacefully. Mom moved from the tub to her bed and barely sighed her contractions through her body. Sometimes she hugged her birth ball and others she laid on her side, curled around her pillow. Always, the doula was there, pressing on her back. Hypnobirthing music played loudly (too loudly for me) in the background.

(Note about the mom: I learned quickly that mom didn't speak up for her needs very often, but when she did, they were very strong indeed. Once, when the doula was at her head, she asked that her husband be there instead; that was a very bold gesture for her. For her to ask that the music be turned down would have been too much of a step out of her stay-in-the-lines personality. I saw none of this prenatally, some of this in labor and a lot of this postpartum. I would have done things a whole lot differently in labor had I known this about her prenatally.)

This was another birth that opened easily with no vaginal exams - no one asked for one or thought about doing one at all.

The dad was hesitant about having anything to do with the actual birth because the first time he'd had amniotic fluid splashed all over him and it wasn't a pleasant experience for him. This time, however, when he was asked, he was ready and willing to be right there to catch his baby. He asked if he should don gloves and we asked if he wanted any and he said he didn't. So, mom on hands and knees, dad got on his knees behind her, and I was there as a guide, because this baby was going to be born in the caul.

The older daughter was in the background and was a tad nervous because mom and dad were preoccupied, but the assistant and my apprentice were letting her know things were okay (note: HAVE A DOULA FOR THE OLDER CHILDREN!).

As the baby was born into dad's hands, I gently lifted the sac over her face as she took her first breath and hollered loudly at the same time. It was great! In one motion, dad caught, I lifted the sac, mom reached down, lifted her leg, rolled over and pulled her baby up onto her belly. It was just great. Mom and dad were ecstatic!

We covered the baby lightly after patting her dry gently (she had a lot of vernix on her) - we had a small room heater in the room to keep the room warm for mom (I love love love having the room heater - women don't shiver anymore with the heater! Hurry for Michel Odent!) and we stepped back.

The doula, however, had her hands all over mom's breast and shoved it into the baby's mouth and the baby latched on within 2 minutes of the birth. I don't think I have ever seen a baby latch on so quickly before. I consider it pretty artificially, however. The doula acted like she was in the hospital - hovering, grasping the mom's breasts, just generally in the space. I tried to get her out of there by giving her tasks - to go get juice and water, but she would run to get those and come right back.

Then came The Bath.

The doula had this brilliant idea that mom had to have a bath with the baby. She'd mentioned it once during labor and I was a little baffled by it because it was the doula asking, not the mother, but left it alone, but now the doula was insisting the mother get into the tub with the baby and the older daughter wanted to get into the tub, too. Well, okay. I explained there would be blood, but if they wanted to do that, it would be fine, just to keep the baby warm. (Initially, they wanted to use the water that had been sitting there! I nixed that and had her draw a new warm bath.)

While the bath was filling, mom had some fruit and went to the bathroom to pee. By 30 minutes postpartum, she was in the tub with her new baby. sigh

I stationed the apprentice at the door of the bathroom with the mom, baby, older child - and doula?

The assistant and I were cleaning the room and were going to start laundry but dad was already doing that. What the heck was dad doing doing laundry? Why wasn't he with his family in the bathroom?

I walk by the bathroom and my apprentice grabs me and says, "The doula says it's okay for the baby to go under the water."

To which I poke my head in the bathroom and say, "Do NOT put that baby under the water! Why would you put the baby under the water?"

Apparently, in the movie Birth Into Being there is an explanation of the closing of the glottus or some such crap and the baby not drowning. Well someone else might want to stick a baby under water on their watch, but they fucking better not put a baby under water based on something they heard from a MOVIE on MY watch on MY license.

My partner said I should have asked the doula to leave the house that very moment. Others have said the same thing.

What I did do, was let her know that one doesn't go by what a movie says to make such serious choices for a newborn. I have since written her a very long letter explaining the liability she put both of us under in doing such an agregious action. I pray she never does that again.

So, the mom and baby get out of the tub and all is progressing normally and about 3 hours postpartum, I begin doing the newborn exam and I get to the part where I examine the base of the baby's spine and what do I find, but an opening. I ask for more lights. It isn't just a dimple, it's an opening. It isn't a protrusion, but an actual going inside the body like-a-dimple-only-much-deeper area above the crack of the baby's butt.

I don't remember the exact order of actions, but they included telling the parents this wasn't a normal dimple, that the baby's legs were fantastically strong and active, which was a great sign, asking for yet more light, trying to see the bottom of the dimple and being unable to, asking for the number of their pediatrician, dialing the pediatrician's number, speaking to the pediatrician and explaining the sacral dimple I found and our discussing the best course of action. I told him her legs were strong and active, but that I did have serious concerns nevertheless. He wanted to know if I had an otoscope and wanted me to see if I could see the bottom of the dimple with it. I told him I did not have one and would not feel comfortable with one if I did because it was that deep. When we were deciding where to take the baby, his office or Children's Hospital, he thought as I did that perhaps Children's was the better place in case a neurosurgeon was called.

The dad had to find a neighbor to take the older child real quick - and no one was home, but thankfully, someone came home just in time or she would have had to stay with the doula or my assistants. It was chaotic for a few minutes as we figured out what to do and where everyone was supposed to go. In the haste, I neglected to direct my apprentice to come along with me. Instead, I instructed her to take the assistant home. I still can't believe I didn't bring her along with me. shaking head

So, at 3 hours and a few minutes old, the family dressed and we headed out to Children's Hospital to get the baby evaluated. The doctor called ahead to alert the hospital and I called them again when we were en route.

When we arrived, they were waiting for us with nametags and we were ushered right into triage, past the full waiting room and the baby was oo'd and ah'd about as her vitals were taken and the dimple was looked at. Mom was standing and I sat her down and had dad stand with the baby, mom filling out the paperwork instead of standing (she was feeling tired and weak). After triage, we were taken into a room where mom undressed her top half and she climbed onto the gurney in there and we undressed the baby and I covered them both with the baby's blankets and the hospital's sheets and blankets to keep them warm and mom nursed her newborn and we sat quietly while they whispered their quiet bonding time. I answered questions when asked and smiled a lot and shared information periodically, but a doctor came in quickly, so there wasn't much time for any small talk.

The doctor came in about 20 minutes after we got into the room and he was very kind and respectful to the family and the baby, asking to touch her, and then looking at the dimple very carefully, not making her cry at all. He had to look and pull deeply to see the bottom and couldn't see it either. He wanted more light, so lit the room and dad held the overhead round really bright light that is the spotlight light we all associate with operating rooms and emergency rooms and he still couldn't see the bottom of the divot. He did not, mind you, take an otoscope and look to see the bottom.

He did, however, say the baby's legs were active and strong and that he could see the bottom of all of the dimple except for one fissure and he'd let the pediatrician follow-up with that. That the ped would surely send them to a neurosurgeon for a consult. I felt a huge sigh of relief that the baby had been seen and then was being released.

We were in and out of Children's Hospital in one hour and 10 minutes and every one of us - from mother and father to newborn to midwife was treated with kindness, respect, and given all the information, privacy and patience anyone could ask for when going through something so scary as facing possible surgery with their newborn.

Mom told me outside the hospital, as we waited for her husband to bring the car around, she didn't know why we had to go, but that when I said we had to go, we had to go. She said she still didn't know what the seriousness of it all could be and I shared a snippet that her baby could have been in surgery at that moment if the spinal cord was exposed and she seemed to understand. I told her how blessed we were to be going home with her beautiful baby. I told her a thousand thank you's for coming in so quickly and readily - it meant so much that she just got dressed and ready. That when she was trying to choose between the pink and purple outfit for the baby and I said, "there isn't time to dawdle" she said, "purple's fine" and she moved with a purpose.

Postpartum, this family has continued being warm and kind towards me. They saw a pediatrician that wasn't their own who barely looked at the dimple and dismissed it saying it was fine. She didn't even touch it! The family asked, confused, has the divot healed? And she said it was just fine, not to worry about it.

When they saw their own pediatrician a few days later, he, too, said that it was fine, but if she had any problems, to let him know.

(If it were me, that baby would be having an MRI, let me tell you! I would not be pacified with such flippancy! It's a baby's SPINE, for crying out loud!)

So, the story ends gracefully with the hospital being lovely to the family, my being a goof forgetting to ask my apprentice to go along to witness a great transfer to a decent hospital, my learning to speak to a doula who hasn't been to homebirths no matter how inconvenient it is prenatally, and I'll leave you with this to make you laugh.

Mom had a few breastfeeding probs that I had to address at odd hours of the day and night, including going over to tend to. I found myself at one time in her shower with her at 5:30am helping to soften her engorged breasts before putting frozen veggies on them afterwards. We spoke several times a day about her breasts for probably 4-5 days. Then I didn't hear from her for a day and a half and I got worried. So I called her. I got her machine. This is what I left on her machine:

"Hey! I haven't heard from you in a day in a half. Are you okay? I'm used to hearing from you. I think about your boobs all day long. Uh, you know... in the good way. Uh..." click

Luckily, she laughed her head off and said she was going to burn it onto a CD and play it at parties - "Hey, listen to this! This is my lesbian midwife!"

I can't stop laughing. One of my Hall of Fame Most Embarrassing Midwifery Moments.

Just gotta keep laughing.

Wednesday, September 27, 2006

Connect the Dots

(Times are estimates at the moment - charts aren't in front of me.)

1. Called to labor @ 6:30 am 9/26

2. Stopped by office to cancel appointments

3. Went to labor

4. Set up for birth on my own (not something I do often since I have the assistant and apprentice with me all the time - I liked it and moved slowly and meticulously)

5. Assistant and Apprentice Arrive about 9:00am (lots of morning traffic - they were 70 miles away)

6. Early labor - mom, dad and family interaction nice and fun

7. Teaching apprentice how not to open a methergine ampule, I slice my thumb, forefinger, middle finger, and hand from knuckle to mid-hand under wedding ring. It provides hours of amusement as I wrap and re-wrap the bandages several times because it continues bleeding; we consider going to the hospital for scrubbing in surgery to get glass shards removed, plastic surgery, placing sutures ourselves, decide on lidocaine ointment (which relieved the sting considerably) after scrubbing with gauze and Barney's Foaming Bubble Gum Soap. Apprentice and Assistant humor my whiny self by starting a chart and asking my hand's progress notes every 10 minutes or so if I don't volunteer it. They rarely have to ask since I am sharing every 2.5 minutes or so. They found some pretty purple bandaids to match my shirt for three of the slices and we hand the major slice wrapped like a fighter until nearer the birth, then I put a regular blue bandaid on it. The Princess one fell off. It was my left hand.

8. Without details, long labor with decision to move to the hospital. 2am-ish 9/27/06

9. JUST as the quiet decision to offer choice to family was being made, the phone rang and my other client that was due was in active labor. Her last labor was a 6 hour home birth of a 10 pound baby.

10. I had 20 min. to decide who was going to go where, gather up the birth supplies and drive the 40 miles to the next house if I was the one going.

11. 4 different midwives could not help... one on vacation, one whose dad was very ill in ICU, one with three moms at term or post-dates and one who was absolutely wiped out from various things with a mom hanging out there. I had no decision but to go to the mom in cranking labor and send my apprentice with the mom who was now heading to the hospital. I took the assistant with me. Neither of us had slept for about 18 hours. I hadn't brought my meds (like a goof). 2 doses down now.

12. Apprentice goes to the hospital with Client #1. I'm horrified that I have to leave Client #1 after all the work we've done during the pregnancy with abandonment issues. I work hard to get my shit together to be present for the next birth knowing Client #1 is in excellent hands with my apprentice while heaving with horrid guilt for leaving her. I feel I set myself up for this abandonment during the pregnancy by telling her I would never leave her. I note I can NEVER tell a woman that EVER again. How could I have known? How could I have known.

13. Assistant and I drive to Client #2

14. Client #2 had vaginal exam that took her from 1cm to 5cm (cervical adhesions broken... history of cervical surgery) and quickly went to 9cm.

15. Things slowed and I napped with assistant did FHTs every hour. When I woke after 3 hours and could barely remember my initials, I called and begged my favorite midwife to come and help me finish the birth. I was in tears I was so tired. She'd said no at 2am. At 7:30am, she said she was on her way. By 10am, she was there.

16. I stayed back and allowed the assistant do almost everything. I called Client #2 by Client #1's name at least 2-4 times. Hugely embarassed, I just shut up eventually after apologizing. I needed to get out of there. I took dad aside downstairs when the other midwife was close and explained that I was medically not safe, that if anything needed a sane decision, I wasn't going to be the one to make it. He expressed understanding and thanks.

17. New well-slept midwife comes

18. I retreat to the chenille-covered slider rocker and sob in the baby's room. I feel like a total failure. It is now 3 doses of meds I have missed. And a whole lotta sleep. I lay back and try to sleep and call my partner instead who begs me to come home.

19. I am worried about my apprentice at the hospital with no car and no sleep and work to figure out a way to get her home. She and I talk off and on. Client #1 still has not delivered.

20. Client #2 seems to have stalled somehow and I can no longer wait and cry. I have to find a way to drive 90 miles home and get into bed. I know I have to pass the other hospital on the way home. Will I stop?

21. Client #1 had been 9cm at home... then many, many hours later, was 7cm. At the hospital, was 9cm and then 7cm twice more. Something very, very odd had been happening. A cesarean seemed very likely despite this being a second child and a previous vaginal birth.

22. On my way home, I sob and shove exquisitely expensive Venezuelan chocolate into my mouth trying to figure out what to do. Stop? Will I be any good? I swerve over the bumpy dots on the road and float dream-like through the miles, seeing floaty weird ghosts out of the corners of my eyes thinking, "Hmmm... perhaps the new baby doesn't need to see these apparitions today."

23. I feel like a failure. Three September clients and all three I have labored with for HOURS and I will have not seen a one of the babies born. Do I scare the babies? I feel so horrible. I just cry and cry as I fly at 90 mph past the exit where my client is birthing (unbeknownst to me).

24. I get a message that Client #1 has delivered - vaginally - after 31 hours - a 10 pound baby girl over an intact perineum with a torrential hemorrhage postpartum. Thank god she was in the hospital.

25. I make it home and nearly fall over in an orgasm scrubbing my scalp and skin with a brush, soap and scalding water... I took two showers in one... one right after the other. I wanted to lie down in there and sleep.

26. I get out and find a message that Client #2 is being transfered to the hospital (!!!!!!!!!!!!!!!)

27. I cannot sleep. Instead, I take my meds and cry.

28. I eat some pasta and cookies and cream ice cream and feel better.

29. I get a call saying Client #2 is being wheeled into surgery. I am absolutely stunned. It's 3:00pm.

30. I finally go to sleep for a couple of hours.

31. I awaken to find that Client #1 is doing amazingly and is doing very well considering it all. We will have a lot of work to process, but she is so strong and powerful, we will do great. Baby #1 was born at 12:00 noon on the dot 9/27/06.

32. I talk to Client #2 and she is so thrilled with her daughter. 9#11oz baby that was coming out ear first (best as they can tell so far) She's now how a homebirth and a cesarean. Wow. Her baby was born at about 4:00pm 9/27/06.

33. I've cried a lot. Stood in front of several clients with no make-up, my hair a gross mess, no bra, clothes icky - and have been honest and tried to stand with no shame. I hated standing there so naked and raw. It was very painful. I forced myself to suffer through it.

34. Two healthy mothers. Two beautiful big girls. One humble midwife who doesn't know what her lessons are that she keeps not actually midwifing anyone but herself.


Could that be it?

Were you able to see the completed picture?

I'm not sure if I know what it all is yet. I'll tell you when I do. Probably after a night or two of sleep. And some regularly scheduled meds.

Friday, July 14, 2006

Baby in the Breeze - a wonderful HBAC story

Sobbing with joy, mom kept saying over and over, “I did it! I did it! I did it!” Every one of us present cried right along with her – so beautiful, so amazing. She clung to her newborn son and dad danced around and she was so filled with disbelief, it was such a privilege to witness.

Through an odd series of circumstances, I became the overseeing midwife for the apprentice I worked with on that last birth before the New Orleans trip. Her mentor midwife was unable to attend this birth, so I agreed to oversee the apprentice as she was the primary – I was to assist.

Wanting a VBAC, mom was diagnosed with Gestational Diabetes earlier in the pregnancy and was on insulin for a few weeks, but then diet and exercise took care of the issue and she remained compliant and healthy the rest of the pregnancy. Because of the diagnosis, she was risked out of midwifery care and into the High Risk category with a perinatologist we sometimes like and who sometimes annoys us. The doctor agreed to allow a VBAC attempt as long as she didn’t go post-dates. He actually said he would do a cesarean at 40 weeks and was adamant about it. Mom was just as adamant she was not going to have a repeat cesarean without a serious reason.

Her last birth found her in labor for 48 hours and she never dilated past seven centimeters. She had been induced (I don’t remember the reason) and the baby remained in a very acynclitic position for many hours. Her cesarean was so pain-filled she couldn’t get out of bed for 48 hours and barely walked for three weeks. She vowed to never do that again.

After that birth, she read voraciously and vowed to do better the next time. When she got pregnant, her self-education increased tremendously and she practically memorized Ina May Gaskin’s Guide to Childbirth.

When time began pressing down on mom and the antenatal testing nurses got snippier and snippier about her “dragging this (pregnancy) out,” she turned to her doula trainer for help in finding a midwife to monitrice her. (A monitrice is a midwife at home, a doula in the hospital and a midwife at home again.) As a doula, mom had attended sixteen births, so knew some about birth from the inside, too.

The doctor, too, began his sales pitch about scheduling a cesarean, but mom deflected the talk by speaking of statistics and her informed desire to have a VBAC. He said he’d “let” her go to 40 weeks, no longer, but he really wanted to do a cesarean at 38 weeks.

With minimal time considering having a monitrice, she instead decided a homebirth would be her best chance at a VBAC. She was 38 weeks pregnant.

Once she passed 40 weeks, the heat was really turned up and she dug her heels in even more. She said she knew this baby would pick his or her birthday and she was going to wait it out.

She went for a BPP every three days and each one, the baby was great, so she was “allowed” to leave, only to return in another three days. She’d gone to her prenatal appointments each week, too, but decided to forego the one from a few days ago because the one before made her want to run crying from their office. The doctor called all the next day and she ignored the phone.

We did a prenatal at 41.2 and talked about all the options. The baby was extremely high, we could feel him/her above the pelvic brim and it alarmed the apprentice and me enough that we talked about it for awhile after the visit. Was this baby that big? Her first had been some over six pounds, could this be four pounds bigger?

She went for a prenatal in the other midwife’s office at 41.4 and the baby remained high. She declined a vaginal exam.

Once again, doing vaginal exams came up for me/us as it seemed apparent doing one was warranted to get an idea of what might be (or not be) happening. Not wanting to rush mom, we didn’t say anything for a couple more days and returned to her house at 41.5. Long discussions about outside limits for each of us ensued, the consensus being 42 weeks – or longer if the BPPs continued being normal. The only wrench in the mix was that the perinatologist was terminating care at 42 weeks and she would no longer be able to get her every-three-day BPPs. We talked about what options there were, including our doing modified NSTs, a 3H enema, stripping her membranes and even just going in and having another cesarean.

To get a better idea of what we were looking at, it seemed important to do a vaginal exam first.

Mom has a history that makes vaginal exams very uncomfortable, so the apprentice checked first and wasn’t entirely sure, so I checked afterwards. We were careful to be respectful of her limits and always asked permission first and listened when she needed us to stop or slow down. She did great throughout. Mom told us not to tell her the dilation because that was the most discouraging part of her last labor.

The baby was -4/-5, 40% effaced, not even one centimeter dilated and extremely posterior. Oh, my. Was that baby too big to find its way into her pelvis?

We went over dates again (for the umpteenth time) and mom was sure, sure, sure. 41.5 she was. I told the apprentice later the cervix felt like a 38 week one, not a 42 week cervix. She agreed.

The plan was to return the next day – 41.6 – and either strip her membranes and/or do the 3H enema. It all depended on how happy her cervix was the next day – and how high the baby was. Why was the baby so darned high up there?

Mom was very concerned about stressing the baby with the enema or stripping… her induction last time led to the cascade of issues resulting in the cesarean. We explained that if the baby was stressed by them, then the baby surely would be stressed by any moderate contractions and it was best to know sooner than later.

We gently told mom she’d have a baby by this weekend. She knew that meant “one way or another.”

We gave explicit instructions to lie on her side if her water broke until we got there (both the apprentice and I live within ten minutes of mom’s house) to listen to the baby. Because the baby was so very high, we were concerned about a cord prolapse. Mom understood.

After the visit, the apprentice and I went to dinner and spent three hours discussing every nuance of the possibilities before us. From the beginning, we had an odd feeling this birth would not end in a homebirth. We felt the baby was large and its being so very high seemed to confirm our concerns.

A comment by the apprentice proved prophetic. She said that sometimes this being a midwife thing seemed to imply we knew everything – could foresee what was to come. How could we know? Isn’t birth miraculously surprising? Couldn’t the baby and mom make some incredible changes in 24 hours? We explored this feeling and I shared that it isn’t that we know it all, but that we have a lot of experience and we are being asked to share that knowledge and experience. Yes, birth absolutely can surprise us – and will – but that it seemed unlikely this mom was going to have a homebirth, much less a VBAC. We remembered that we didn’t really see her having a homebirth from the first time we met her. (Of course we allow women’s experiences to unfold, but predictions, with most people, tend to happen. A hunch? Premonition? Prediction? Projection? Some things that are good for us to explore.)

We went to bed dreading the next day’s news to mom.

The apprentice was called at 2:00am – contractions had begun in earnest, but mom didn’t need us there yet.

At 2:45am, mom’s membranes ruptured. She called and got onto her side as we threw our clothes on and headed over.

I got there first, but not by much. Going in, mom was moaning delightfully, lying on her side and I grabbed my doppler and listened to a baby whose heartbeat was clicking along beautifully.

The apprentice got there, the doula (also a student midwife) soon behind her. My apprentice’s phone was busy and she didn’t answer her cell phone. She didn’t get there until mom was pushing.

Laboring happily, and I do mean happily, mom moaned and rocked, needing her husband’s love and touch more than anyone else’s.

When the apprentice and I had a moment alone, we looked at each other and agreed that something had shifted... it now felt like she could have this baby at home - and vaginally. Niggling worries still remained, but at least there was more hope than the day before.

Very quickly, we understood this birth wouldn’t be like most. Mom had to have dad’s hand/fingers on her clitoris. Over and over, she would nearly shout for him to touch her “clit.” Off and on, she would remind us that Ina May said how important orgasmic birthing can be – the midwife’s mantra quoted from Ina May Gaskin: What got the baby in there is going to get the baby out. At one point, mom said, “No shame” and we laughingly (and lovingly) said she was welcome to do whatever she wanted and needed to do to get her baby out. If his hand wasn’t on her vulva, her own was. Good for her!

She wanted more intensity on her clitoris at one point and asked if anyone had a waterproof vibrator. She was absolutely serious. None of us did. She later told us we needed to put that on the list of supplies required for birthing at home. What a great idea! She then asked a couple of times if we had something she could clip to her clitoris… a clothes pin? Blinking, all of us were so surprised and couldn’t think of anything to use. Mom would sigh and say, “Never mind,” and command her husband to put more pressure on her clitoris. “More!”

One of the times we left her and her husband alone to cuddle, the apprentice and doula went out to listen to heart tones. Dad was nuzzling mom’s nipple. When he stopped, the mom asked what he was doing. He pointed out the apprentice was there and she said something like, “You’re going to let two women watching hinder your sucking on my breast?” and he said, “I guess not,” and continued suckling while they gently listened to the baby and excused themselves quickly.

The first part of labor, dad was filling the AquaDoula and mom could not wait to get into the tub. Activity around mom – our setting up, dad and the pool, her son getting ready to leave with grandma – frustrated her, so we all slowed down, sent her husband to be with her while we took over the tub filling. She was much happier.

Mom wanted to birth outside. Living in a standard neighborhood, she wasn’t concerned at all about the birth songs she was sure to emit. She wanted some physical privacy, so dad made a grotto next to where the birth pool would be set up. Plants and a fountain were surrounded by bamboo shades and the entire area felt so peaceful and was really quite lovely. Purposeful beauty. We all smiled.

During labor, besides her vulva’s needs, mom insisted on being jammed in the lower back. During her first birth, she’d been pressed so hard by her husband – at her request – she was bruised and unable to be touched there for several days postpartum. We could see the same was going to happen this time. Alternately, she wanted hot packs, but also needed those pressed deeply in. The doula had some packs that got hot quickly with a zip and she used those for awhile, too. What seemed so hot to the rest of us brought sighs of pleasure to mom.

A few times, we heard mom starting to push, but after a couple of hours of not much progress, it seemed important to see what was going on. The apprentice did the first vaginal exam of labor and mom was seven centimeters and about 80% effaced. The baby was also at a zero station!!! (That baby moved down!! Shocked the hell out of us, you know.) Mom understood not to push really hard (remember, she’s a doula herself), so stopped the pushing, even at the peak of contractions. This place in labor was challenging for mom since she’d stalled at 7cm last time. She didn’t get frantic or upset as some women do, but kept going, determined to push this baby out her vagina.

A couple more hours later, mom really was struggling to not push, so we encouraged her to push when she needed to. Worried about pushing too soon, the apprentice did another exam and felt a cervical lip. Mom was elated! I asked if there was any molding and the apprentice wasn’t sure. She asked me to do another exam to make sure she was feeling the right thing and my exam found mom complete and a great deal of caput – which was probably causing the earlier pushing. The caput was a +2, but the head still at a zero station.

Before doing this latest exam, mom also asked to be catheterized because she could not pee. She could eek out a little bit during contractions, but it just wouldn’t leave her bladder. Climbing out of the tub, she laid down on the futon covered with yoga-like mats and a sleeping bag. The apprentice had seen catheters placed many times, but had never done one herself, but was exactly perfect in her placement and we removed about a cup and a half of urine. She ah’d and ah’d and ah’d about the relief and wanted to keep the catheter in there, it felt so good. Laughingly, we explained it can’t be left in and she sighed her okay as it was removed gently. Later, mom tells us the catheter being in was orgasmic. Not nearly orgasmic, but really felt orgasm-like in the relief it offered. She said she didn’t know why we gave her warning that it might not be a pleasant experience – “Don’t tell women that!” She had so much to teach us!

Pushing began in earnest. There is no way to tell you the utter joy mom felt in pushing. She literally glowed and smiled and hollered, “This is so great!!!!” throughout the 2+ hours of her second stage. She pushed and grunted and knew exactly what to do – her body leading the way. Side to side, knees to butt, mom moved all over the AquaDoula, instinctively knowing what movements to do to get her baby born.

Right at two hours, the baby’s heart rate, which had been perfectly normal throughout, zoomed up to the brink of 200 beats per minute (normal is 120-160). Alarmed, I asked mom to get out of the tub, that it was time to have a baby. The apprentice, who was the primary midwife at this birth, looked at me confused and I asked her what the beats per minute count she’d gotten. She said “around 160” and I shook my head no and told her it was 190-200. Mom got out and onto the futon as I explained the baby was now telling us it was time to be born.

Mom is GBS positive (and didn’t want antibiotics unless warranted), so that was a concern, but she’d also been in the hot tub for several hours. Perhaps the baby was too hot? (The water wasn’t much higher than 98 degrees.) Mom’s temperature was 99.7. Yikes!

Once again, I told mom it was time to birth her baby. We could see the head (caput) coming and she was doing a great job pushing. I encouraged the apprentice to go in her vagina and press her ischial spines apart to help the baby come out sooner, giving some assistance. Heart tones were still above 180, but at least they were some down. The baby moved great with each deep push, slid back up in between. With the apprentice’s help, including putting her fingers at the bottom of mom’s vagina, the birthing woman was able to push more effectively. She continued putting pressure on her clitoris and cheered as she was bringing her baby out. Feeling how much of the head was out helped her enormously!

“I’m doing it!” she would say over and over and we were filled with joy that our predictions were being proven absolutely incorrect.

Two contractions before the baby’s head was born, mom rested on the futon, opened her eyes and looked at the sky. She said, “What a beautiful day to have a baby. Feel the breeze?” And we all closed our eyes and felt the wind blowing through their grotto, around the porch, through the trees and tinkling some faraway wind chime. It was a moment of peace during some quick-motion movements to help a baby be born.

The baby’s head was born, already somewhat diffused, and didn’t rotate. Mom stopped having contractions despite some nipple stimulation by dad and me, so she was encouraged to push the baby out anyway.

I encouraged the apprentice to assist the baby out. She pressed downward on the baby and there was minimal movement, but when she stopped, the baby slid back inside. I said, “Do it again,” and she repeated the movement, the baby sliding back in again. I got mom’s legs back and the apprentice said, “Switch places.” I said, “No, you can do it,” and put my hands over hers so she could feel how to assist a baby out that needed help. With not-so-hard traction, the baby finally slid out (2+ minutes after the head was born – no contraction at all) and flopped up onto mom’s belly with her help. (I’d call this sticky shoulders, not a dystocia.)

Elated, she kept saying, “I did it! I did it!” and I busied myself drying the baby and making sure he (a boy!) was going to breathe spontaneously. After a few moments, he opened his eyes, a little stunned at his arrival and grunted a hello that let us know he was going to be perfectly fine without any resuscitative efforts at all on our part, just stimulation with drying. Meconium spilled out behind the baby and lay on the chux under mom’s bottom, along with a goodly amount of blood.

My apprentice had arrived during the beginning phases of pushing and took over 200 pictures during the birth. Happily, it was outside and no flash was needed, so pictures were no intrusion whatsoever. Mom commanded us several times to take pictures and get the video on so she could get every part of labor and the birth. It was a joy to do so!

As soon as the baby was making more noise and his spirit firmly on the earth, mom started crying tears of joy. All of us were crying (except the apprentice still in working mode making sure mom wasn’t bleeding too much – I observed her from my tearful state) and it was such a beautiful, beautiful few minutes with salty tears and words of joy and praise lifting into the breeze that brushed against us in the mid-morning sun.

The placenta was born without problems, no undue bleeding or anything – the blood on the chux pre-placenta had come from some decent second degree tears deep in the vagina – we found out later.

After some cuddling and cleaning up, the cord was cut (after asking permission) and dad held his son as mom walked across the yard, up the stairs and across the house, then climbing up onto her bed – all the while squealing, “Do you see this?! I’m WALKING! It’s an hour postpartum and I am WALKING!” We saw and we applauded her.

The doula made scrambled eggs and bagels for everyone to eat while the apprentice did a great suturing job with my watching over her shoulder.

Southern California is in the middle of an oppressive heat wave. Air conditioners in the luckiest of homes run continually as this region simply isn’t used to such heat. The breeze outside did not translate to coolness inside; we were sweating our heads off. I put a fan directly on the apprentice suturing – suturing can be sweaty work even in frigid temperatures. One window air conditioner in the dining room found us girls jockeying for position in front of it, purposefully finding something we needed to do outside the incredibly hot bedroom.

I took the baby’s temperature and it was 99.7!! I yanked those blankets off the baby and removed the hat and he cooled off when I took his temperature 15 minutes later. It really was hot as Hades in there!

While he was naked, we weighed the baby.

9 pounds 4 ounces. Nearly three POUNDS bigger than her last child.

The doula set out making mom chocolate cake while we cleaned up things before mom wanted to get in the shower to get refreshed. While she was in there (my apprentice staying near in the bathroom, chatting with her), dad held his baby and the other apprentice and I got the top sheets and plastic that was pinned to the bed off of there and her new clean sheets ready for her return.

Once she was tucked into bed, dad quickly showered as mom held her baby to her breast – he nuzzled a few times, but was just beginning to seem interested in getting some colostrum.

Lots of jokes were made, started by mom, about her (said sarcastically) gestational diabetes and her giant post-mature baby. Once we really examined the placenta and showed mom how absolutely gorgeous it was, we knew there was no way… NO WAY… this baby was 41.6 weeks. There was one sand-grain-sized calcification and otherwise, it was a gorgeous, fully liver-colored placenta. No staining. The sac remained strong and didn’t shred as late membranes are wont to do. Confused, I mentioned the placenta looked like a 38 week one.

Mom could not wait to call the doctor who threatened her all those weeks.

Seeing this, I did a cursory newborn exam and declared the baby at about 38 week’s gestation. He lay on the bed with his arms and legs open like butterfly wings… flat on the bed. He had some, but not much cartilage in his ear pinna. His breast buds were not well developed, he had creases only ¾ of the way down the soles of his feet and his skin showing blue veins and a beautiful, creamy-textured pink softness.

Later, I remembered how I’d said her cervix the day before was more like a 38 week cervix, not a 42 week one. Suddenly, it all came into focus and mom said it sure might have been possible to have conceived two weeks later than she originally thought, but ultrasounds and all measurements pointed to the due date we all had been working under.

Had she been cut at 38 weeks when they first said they wanted to, that baby would have been 34 weeks gestation. Even at 40 weeks, the baby would have only gestated out to 36 weeks. Mom was so, so thankful she was adamant about waiting. She said, over and over, she knew the baby would pick his own birth date. She knew he would know and he wouldn’t die inside her waiting to be born. She was right.

When the cake was done and frosted, we all had hefty slices and sang Happy Birthday to the new birthday boy. More tears mixed with the sweet chocolate on our lips.

Mom was given her postpartum instructions (the apprentice had already done a more complete newborn exam) and we all stressed her need to relax. She wanted to get up and cook for everyone she felt so good! I laughingly told her, “You VBAC moms are the worst in trying to keep down! Y’all are so danged high; you think you can conquer the world!” Well, they can do that… just not clean it within the first two weeks of the birth!

Four hours postpartum, we’d packed the supplies, done two loads of laundry, cleaned the kitchen, made sure the porch was cleaned up, got the chairs put back where they belonged and readied ourselves to leave.

Kisses all around, thanks for the honor of attending, thanks for our being there, thanks for the glorious breezy birth – everyone so high with love and amazement – no one more than the apprentice and I who were brought to our knees in humility. Birth, many times predictable in its normalcy and ability to follow patterns, sometimes jumps right up there and shocks the hell out of us… making us eat our words.

Mighty tasty chocolate words they were, too. I am glad to have heaping servings of this time of humility any time.

When asked postpartum what had shifted, mom said she prayed the night before - allowing fear and the baby to be born all at the same time. She kept picturing them both pouring out of her body and she felt, for almost the first time, too, that she really was going to birth this baby vaginally and at home.

A baby born in the breeze.

Stepping outside in the pressing afternoon heat, I stopped as the wind picked up and blew across my face and arms and legs.

I, too, was re-born.

Tuesday, June 27, 2006

New Orleans VBAC Story

I stumbled out to the back porch and sat in the upper-90 degree muggy heat, cell phone in hand. As I dialed the phone, hot tears began falling. My apprentice was at a birth, so I re-dialed one of the very experienced student-midwives – the assistant at the last birth. When she answered, I began telling her how we’d been in labor for so long, how she’d been pushing for so long, how the baby was doing fine, how tired I was – by this point, I was blubbering and she asked me to slow down, take a deep breath and try to speak more clearly because she couldn’t understand me. A flood of emotion streamed out of my mouth and I could barely contain my distress at how tired I was and how worried I was my client was going to go to the hospital and be cut. Once again, the midwife asked me to slow down because she couldn’t understand me through the tears.

I took several deep breaths and began at the beginning.

I was called to check on mom right after midnight, but sent mom to the bath and to bed and left to sleep again myself. I was awakened at 4:30am and once I got into the house at 4:45am, I could tell mom was finally in true and active labor. Vitals were great, the baby sounded wonderful and mom wandered and moaned with the regular contractions.

Her two-plus days of prodromal labor had taken its toll on everyone in the house. No one more than mom, of course. We let her husband sleep for as long as he was able to and called the doula to find her way over to the house when she was able to (she has kids she needed to get to a sitter). Come to find out she’d spent the night awake babysitting some drunk co-workers and hadn’t gotten any sleep at all.

Wandering, leaning, sipping water, mom puttered around, moaning lightly with the contractions that were 2-4 minutes apart and lasting almost 60 seconds. She’d been watching and timing contractions so one of the first things we did was to cover the clocks. It was almost a symbolic gesture in that she never once looked at them again or even asked what time it was. Around 9:30am, I reminded her to take a medication she needed and she thought she was very late taking it, thinking it was 4pm or so. When we told her what time it was, that was the last time mentioned for the rest of the day until the birth of the baby.

Dad woke up somewhere after dawn and then the girls got up and were sent to a neighbor’s house for the day. They had a great time, coloring for mom, reading – having fun that wasn’t labor watching.

My client’s mom was up from the first time I was called over. She, a trooper throughout, was supportive and reassuring – having 8 kids of her own.

An amusing sidelight: All three of us – laboring mom, her mother and I all share the same first name. The birthing mama and I also share the same middle name! And it isn’t something usual like “Ann,” either. It got confusing with all the same names in the house, so I was nicknamed my name with _wife on the end to designate me from the others. Funny!

When the doula came over, she was exhausted. She grabbed a Coke, sat in the glider in the bedroom where mom was laboring and promptly fell asleep. She looked much like a toddler in a car seat… you know, when they are all curled sideways, hunched over, looking so incredibly uncomfortable, but they never wake up? That’s what she looked like. Tired myself, I shooed her out of the room about an hour into her nap. She then curled up on the couch, pillows on her head and slept 2 more hours. I teased her about it all afterwards. She said she never would have done that in a hospital birthing woman, but felt like there wasn’t a lot to do. That feeling is expressed often by doulas attending homebirths, especially the first few times.

Mention needs to be made of the client’s dogs. She has a Bouvier that weighs 105 pounds and a Staffordshire Bull Terrier – both of which are her dearest friends and a great support to her when she is scared or worried. Her first labor, she hugged the Bouvier for hours and expected to do the same this time. During some of her prodromal labor, she did in fact hug her puppy, but they merely stayed close while she was in labor, sometimes on the bed, other times at the foot of the bed.

The Bull Terrier seemed to have eaten something horribly rotten the night before and was sharing the foulest farts in the history of farts. When the doula woke up, she was barely coherent and the dog farted and the doula nearly passed out from the stench. All of our eyes were burning and the doula really did turn sheet white and sway. I was worried she was going to fall into mom so had her move to the glider rocker where she put her head between her legs. The farts were disgustingly amusing. Mom doesn’t remember smelling them at all! Let’s here it for LaborLand!

At one point on the toilet, mom wasn’t sure if her water broke, so I got out the nitrazine paper and it turned dark blue. Ayup. Amniotic fluid there.

Labor continued for awhile and it got to a point where mom was pushing, but nothing was happening, so I asked if I might do an exam to see what was happening. The baby was doing fine, but didn’t seem to be budging. An exam showed she was 9 cm. Light pushes for a few more contractions and then the urge was overwhelming.

For a midwife who tries hard not to do vaginal exams, this birth had more than its share of them. Something wasn’t right and I couldn’t figure it out. Over a several hour period, mom went from 9 to complete and +2 to 8 and -1 to 9 to a lip… it was the strangest thing. Frustrated that position changes, talking, wonderful pushes and her water breaking again, this time with a humongous gush that soaked me enough to send me to change clothes didn’t show any progression towards birthing. Fluid was clear again, baby sounded great, but I had exhausted my mind and ideas. It was time to call someone.

During the labor, mom leaned on dad physically and emotionally. He was loving and kind and her mom was equally loving and supportive. As time went on, however, I could see their growing nervousness which turned to agitation and then to franticness regarding the situation. I tried to calm them as best as I could, but my main focus was mom and trying to figure out what was going on.

It’s interesting writing this because in the moment, all of this wasn’t entirely conscious. A lot of this is an undercurrent of care as a midwife. I don’t remember thinking: Why is the baby stuck? at all. It wasn’t until I called the midwife and she suggested perhaps there was a cord holding the baby up that I was able to put into words my frustration and concern.

I so wanted her to have a VBAC. While I try hard to allow each woman to have her own walk, I also do have dreams and wishes for their births – the same as they do for themselves. After my sobbing talk on the phone, I pulled myself together enough to talk to mom in the tub (she was trying not to push for an hour to see if that helped the cervix issues). As soon as I got in there, she said she can’t do another hour. The baby had moved into a position that dug her feet into mom’s ribs and she was in excruciating pain. Two other points of stabbing pain on either side of her spine made it difficult to concentrate on the contractions at hand (she tells me later). The decision was made to transfer to the hospital.

I wept some, apologizing and they said it was perfectly fine, not to worry at all.

During the times we spoke leading up to the birth and even in the hours before labor began, we’d assumed that any trip to the hospital would be for a cesarean. It was a given. Later, mom tells me she never even had one iota of a thought that she’d have a repeat cesarean as we talked about going in. She isn’t sure where that belief came from – and her husband shared it – that it seemed odd to have me sad that we were moving to the hospital. She knew surgery wasn’t in the cards.

Then we set about getting to the hospital. I called the doctor, but her doctor (who’d said she’d come in for the birth and asked that she’d just come in before crowning, please) wasn’t on-call, so I spoke with the doc on-call. She insisted on talking to mom and it was then I knew we were really heading in and would be there in about 15 minutes.

Besides the cervical flip-flopping and stopping pushing periodically for a few minutes, she’d been pushing for 5 hours by the time we left the house.

Looking back, it’s so interesting to me that I didn’t even have one iota of a concern regarding the length of time she was pushing. I didn’t worry for her uterus at all. I worried for her stamina and peace of mind, but health-wise, I knew she was strong and healthy and could do this; I never had any doubt.

During the 90 minutes or so before transferring to the hospital, I could see the tension mounting in the grandmother and husband. Imploring eyes became nervous agitation and by the time mom was in the tub trying not to push again, I could tell both relatives had reached their tolerance-for-a-homebirth limit.

I prepped mom with the happenings in the car and how fast things move in the hospital, pokes, BP, temp, questions and more questions. She nodded her understanding, got in the car and I followed in the doula’s amazingly trash-filled car. I brought the birth stuff in case she delivered on the way. One can wish, right?

At the hospital, we entered in the ER and admissions had too many questions for us to answer. Fumbling, we finally found mom’s paperwork, told them she was pre-registered and said, “She’s going to have this baby right here if we don’t hurry up!” The security guard grabbed a wheelchair and nearly shouted, “Not down here she isn’t!” and took off with mom, zipping faster than any wheelchair with a laboring mom has any business going. The service elevator wouldn’t come, so we took the regular ones – they took so long, all of us old and fat people caught up enough to get into the elevator at the same time.

In L&D, the nurse who weighed twice what I do told us to go into the room directly across from the nurse’s station. The one nurse and an LPN were the only people there. When they were in the room, no one was at the desk. We never saw another nurse at the desk the entire time, even when grandma, the doula and I sat in the hall waiting for the doctor to insert the epidural.

When she got into the room, my client was handed a gown and she said she didn’t want one. What was very interesting about the gown experience is that it was a large-sized gown! The large gowns were the norm and the smaller gowns were the exception. How clever! The nurse didn’t seem concerned about the gown issue except in the door and curtain remaining closed to protect my client’s privacy. There really wasn’t anyone ever in the hallway, so it seemed, moot, but we were respectful and complied anyway.

The nurse, Jill (not her real name), assessed my client’s contractions quickly and pulled out a sterile glove after I told her she’d already had rupture of membranes with clear fluid. We could tell she was giving all of us the once over, who are these people? and she firmly, but kindly explained to my client she couldn’t call the doctor until she examined her. She didn’t even want to hear the baby’s heart tones until she’d done an exam, so my client, naked to the world, hopped up on the bed and had yet another vaginal exam. She was 8 cm and -2. This was the craziest cervix I’d ever experienced!

What could make a cervix do this back and forth trick? When I was crying and talking to the other midwife, she reminded me that short cords do this sometimes and they needed some bungee time to stretch enough to allow the baby to be born. While I’d heard of such things, I have only seen it happen once or twice, but nothing this dramatically. To go from complete and +2 to 8 and -1… well, that was just so odd. And it is important to note that her cervix was not swelling, either. She was completely effaced – an aspect that never changed. It’s just that there was cervix there. And then there wasn’t. And then there it was again. I was baffled.

When the nurse heard my client was a VBAC, she said, “So you want to do this naturally, right?” and my client burst out, “NO! I want an epidural!” Confused for a moment, I heard, “You want a vaginal birth” whereas my client heard, “You don’t want medication.” Jill quickly said the anesthesiologist was already on the way in for another mom, so she’d have to get the IV going quickly so she’d have enough fluids on board for the timing of the epidural.

As Jill moved around the room, I could see her trying to figure all of us out, too. Doula, grandma, dad, midwife and mom – all encouraging mom and helping her get comfortable. I didn’t want to seem too know-it-all, but I also wanted her to know I had the clue bucket in my hand. Before 10 minutes was up, I casually made a comment that we were a room full of nurses and midwives – (grandma is an RN) – and Jill visibly thawed.

Suddenly, there was something for everyone to do.

Jill went for the vein in mom’s left hand, but it blew (bad) and she had to move to the right hand. Dad was holding the gauze on mom’s bleeding hand and I stepped over there to take over so he could be with her without having to do clinical things. The nurse got the vein in her right hand quickly and I handed her the IV tubing and started it running.

Sitting here writing, it sounds so silly to mention the things I did – like I am some big shot or something, but that isn’t how I mean it at all. What I am sharing it all for is the aspect of how needed each of us was… how we all worked as a team. There was never any turf war between us at all. At one point, Jill said her job was to stay out of our way as much as possible so mom could birth. Huh? Where did she come from and can we clone her?

Jill asked us to put the pressure sleeve on the bag of Lactated Ringers and grandma began doing so. I looked at this piece of equipment and felt like I was in a foreign land. I’d never seen such a thing! I’ve always had to mash the bag to get it to run wide open. Who invented such a cool device? (I am not sure of the technical name for this sleeve, either, forgive me if I am calling it the wrong name.) Grandma hung the bag by the sleeve instead of the LR and it began slipping out, so the very tall doula replaced the sleeve over the bag of fluids and we pumped the thing up as high as it would go. The pump-y thing was just like a blood pressure cuff pump… I knew what to do with that. Once the contraption was working correctly, a liter of fluid ran into my client in less than 10 minutes. Wow!

Before long, the anesthesiologist wandered in – in tennis whites with Nike tennis shoes – he looked 12 from afar! (He really was about 50 when we spoke with him later.) Happily, the doula, grandma and I stepped out so mom could have the epidural of her dreams. She’d been phenomenal and deserved to have some pain relief. Those three stabbing points were still excruciatingly attacking her; she could barely contain her joy at seeing the doctor. The nurse had gone out for the epidural tray, a far cry from the epidural cart I am used to. The doc never gowned (that I saw) and came out of the room not 8 minutes after he walked in, mom in complete comfort almost immediately. I asked if she’d had a spinal (because those usually take effect so much quicker and are easier to place), but the doctor said no, it was an epidural. This was confirmed by the nurse later, too, when I was really confused by the lack of a pump or thread or anything. Apparently, I am not so hip on regional anesthetics.

In the hallway, we three sat in wheelchairs and they were all the extra-wide wheelchairs. Large-sized gowns? Super-sized wheelchairs? Was I in the land of the Fat-as-Normal?

The doula told us she had to go to work and wasn’t sure how to tell mom. Should she just go? I shook my head and encouraged her to just say it outright. She said if she was doing a regular doula job, she would never leave her, but being in such good hands, she felt she should go to work.

As soon as we all re-joined a now-chatty mom, Jill said the doctor was right behind her outside the door. The doula explained that she needed to go to work and mom was fine with it, so we lost one part of the birthing team.

When mom said she felt intense pressure, the doctor came in and was all smiles.

During the pregnancy, mom had another female doctor who’d paid lip service to having a VBAC. As the pregnancy progressed, however, it became more and more apparent that she really didn’t believe in my client’s abilities to birth vaginally. At one particularly disturbing visit, my client was told she wouldn’t be able to birth a baby bigger than 6.5 pounds out her very small and odd-shaped pelvis. The last straw for desiring change came when mom said she wanted to have a tubal ligation after the baby was born and the doctor was crazy angry that she wouldn’t just have a cesarean so she could do both at once and “not waste time.”

Finding this new doctor, who’d had two cesareans herself, she learned she had an 80% VBAC rate. The first doc said she could do that too “if she was picky” with the patients she chose. The new doc, however, takes anyone desiring a VBAC and works her ass off to provide just that.

My client had two prenatal visits with the new doctor before seeing her in the LDR. One visit was a pelvic exam that had the OB blinking in confusion as she said mom had a “perfect gynecoid pelvis” and would be just fine delivering vaginally. At the second visit, the doc asked if she planned on staying home for a good part of her labor and my client hesitantly mentioned her friend the midwife coming to be a doula for her. The doctor didn’t bat an eye and asked if I’d be able to take heart tones during labor and was told yes, I would. She then laughingly asked if my client could please come in before crowning – it makes things much easier.

As the doctor walked in, I said to her, “You asked that we come in before crowning… well, here we are!” She was a delight, introduced herself all around and asked how mom was doing. “Great now,” was the answer. The OB grabbed a sterile glove and did a vaginal exam saying the baby was so low! That mom was complete (she felt around for a goodly amount of time, surely checking the baby’s position, too) and a +4. What!? I looked down and saw no sign of a head. + 4? The nurse’s eyes bugged out of her head and the doc said mom could keep pushing and she’d be back in a few minutes.

So, the bed was broken (down) and we began helping mom push with the contractions. As she pushed, the heart rate was fine and dandy. However, when she stopped pushing, the heart rate began dipping lower and lower. Oh, that stinking cord again! We flipped mom on one side then the other and then just said, “It’s time to get the baby out.” I went to the desk to get the OB and she came in, gowned and said, “Let’s have a baby!”

Pushing, pushing and more pushing didn’t bring that baby down, but did bring the heart rate down in-between pushes. At first, the heart rate was in the 80s in-between contractions, but then would climb to 100 – 120 during the contractions. The doctor looked up and said, “It’s probably a cord somewhere.” Aargh! I was never more sure of that than that moment!

Calmly, the doctor asked the nurse to go get the forceps. Huh? They aren’t on the delivery table? I looked at the delivery table and saw how sparse it was decorated. Minimal instruments – something I’d never seen before this moment – lay on the sterile table… no forceps, no vacuum under the table… one set of suturing instruments. Interesting.

As Jill was walking out the door, the OB was gowning and another nurse breathlessly walked in and said she (the doctor) was needed for a stat section. The OB said she couldn’t go and the nurse said, “But they need you!” Looking at my client and the monitor, she continued gowning and said, “You’ll have to find somebody else, this baby is important, too.” This was yet another sign of the lack of personnel the hospital was working with. One of many.

The LPN sat at one of those hospital tray thingies and charted the whole time. She never got up from her seat and never said a word, just charted everything as it unfolded. Picture her quietly sitting throughout the story.

Jill came in with the forceps and the doctor asked her to alert Peds that they would be needed for this birth. Jill left as the OB clanked the forceps together to scare the baby out (sometimes just the sight of them is enough to inspire moms to push harder and faster). When Jill returned, she said that Peds was in with the section and they would come in when they were finished. This was nurse-speak for “We’re alone here.”

The OB asked me to go turn the warmer on for the baby, so I did that quickly and returned to mom’s left side. Jill was on her right, dad at her head above me and I am not sure where grandma was. Down near the bottom?

My client was pushing with all she was worth, even with the epidural, and the baby remained high and immobile. It was time for the forceps.

I’ve seen forceps used a lot, but never quite so skillfully as this time. The baby was absolutely not a +4 – was possibly at a zero station, perhaps higher. The OB was using mid-forceps on the baby – it was easy to see because of how much of the instrument was inside mom. Without an episiotomy, she pulled on the baby with gentle force and we watched as the baby did the same odd heart rate pattern of falling in-between contractions while climbing during pulling and pushing. The baby’s heart rate was dropping into the 70s, but wonderful Jill never said a word and all mom heard was, “Heart rate’s over 115.” It didn’t register that it was over 115 and that was great news, just that it was over 115.

Jill put oxygen on mom and I encouraged her to breathe deeply in-between contractions. She listened well.

Neither mom nor dad knew how low the heart rate was going and that was just fine and dandy to me. Dips into the 60s and the low baseline being in the 70s was typical. Climbing up to the teens during pushing and pulling happened every single time. The OB and I looked at each other and waggled our eyebrows. She chuckled and said “This baby sure likes to be pushed and pulled,” to which mom replied, “She better, you’ve seen her sister!” It was a light moment in a time of growing concern.

Forceps were used for 12 minutes that I counted. I had never seen them used for so long before. She never asked for the vacuum and she placed and re-placed the forceps 4-5 times. Miraculously, mom never had a perineal tear.

At one point, mom made a comment that went something like this: Don’t make my baby a Sylvester Stallone – and I shot her a look of, “Good GOD, don’t say something like that! That’s lawsuit talk right there!” Amazingly, the doctor nor the nurse understood that she meant not to paralyze her child’s face with the forceps and just thought she was talking about the oxygen. Later, I explained to mom that no doctor ever purposefully paralyzes a baby with forceps or anything else. Accidents happen. Sure there are negligent docs using forceps, but this wasn’t one of them. She wasn’t teaching an intern or allowing a resident to have a hand at the tool; she was getting a pretty darned depressed baby out of her body as fast and as safely as possible.

Once we could see the head – now at a +3 or so – then the forceps were removed and mom exhorted to push the baby out on her own. The heart rate was still doing its funky thing, but at least an end was in sight – and it was a VBAC end.

Instead of using the metal forceps, the doctor used her hands as forceps to help pull the baby forward and down. Goodness, this child was being a challenge!

As glorious as this doctor was, one small complaint is all I have, but I wasn’t in her head, so can’t really be all that mean about it. She started doing some incredibly aggressive perineal massage... easily pulling mom’s vagina and labia out about 6 inches from her body. Over and over, she pulled and pulled and pulled her body – I thought I was going to be sick, she was pulling so hard. I say I don’t know what was in her head, but perhaps she was nervous and wondered if there really was enough room. Maybe she was nervous and this was her way of tending to the fear. Maybe this is her normal treatment of a vagina. If so, ACK! If I ever get the chance to see her again and talk to her, I will surely ask her what was on her mind as she manipulated my client’s body so aggressively. Postpartum, mom’s perineum was bruised so badly it looked like someone took a baseball bat to it. I’ve seen bruising and I’ve seen swelling, but it was nothing like this. From leg crease to leg crease and clitoris to anus, a hugely purple bruise along with some grand varicosities helped to keep mom off her butt as it healed. She had been sitting at the computer before I saw the extent of the bruise and could see one of the varicosities bleeding and explained that if she didn’t get off her bottom she could very well end up back in the hospital with a hematoma or worse. It was all she needed to lie down, where she remains a week later.

The baby finally moved lower and we could all see her crowning. I encouraged mom to open her eyes to watch her baby be born, but she couldn’t see over her belly yet. She tells it that as the doctor lifted her head upwards, then she was able to see her child. I pulled mom’s arms out from under her knees and towards her vagina so she could bring her baby out onto her belly. As she did, it was so wondrous and I wanted to shout with glee. “She did it! She did it!” It was news for all to hear.

I ran to the warmer for blankets (I think the doc asked for them as she was being born) and covered her as soon as she was out and on mom.

A massive amount of meconium followed the baby’s entrance into the world and the baby lay flaccid and quiet on mom’s belly. Jill took the O2 mask off mom and gave it to me and I put it next to the baby’s face, being careful of her eyes (mom and dad saw that, yes, it was a girl). Both Jill and I rubbed the baby and I went to get new warm blankets and we changed them out. I called one minute, but Jill said we’d already passed it and gave the baby a 6. I laughed and said she was a whole lot more generous than I would have been. By the time we hit two minutes, the baby was still not happily breathing (very gunky), but her heart rate was a fabulous 140. She was still totally flaccid and her color, while not horrid, still left a lot to be desired.

Somewhere in there, the OB said, “Short cord,” and the cord was cut – she told mom, “Don’t worry, I waited until it stopped pulsating.” Mom laughingly told me she couldn’t have cared less at the moment, was flattered the doctor even thought of it. (I can’t imagine a cord being done pulsating in less than 2 minutes, however – unless it was pretty flaccid to begin with.)

Short cord.

Was she pressing on the cord in-between contractions and then lifting off of it during the pushes and pulls? We’ll never know, but it was very reassuring to know that it was, indeed, a short cord.

sigh

“Carry her to the warmer,” someone said and I grabbed the baby and had mom kiss her before lifting her off mom’s belly and walking her to the warmer.

Never before, nor can I imagine ever again, will I experience carrying a newborn to the warmer. Me, a non-hospital, un-insured, not-under-contract person being asked to do something so supremely hospital-oriented – yet another moment of internal shaking of my head wondering, “Is this for real?”

I turned on the suction and the nurse gave me the DeLee to hook up to the tubing and she began suctioning as I stimulated and changed the blankets yet again.

The baby finally began perking up, but remained pretty darned quiet. I called dad over because babies always respond much better to their parents than to their midwives and he was so loving to her, touching her hand and hair and talking to her to bring her into her body. She never really hollered like many newborns do, but she showed her irritation and left it at that.

I went back to mom and saw the doctor already beginning to suture. Mom had a deep first degree vaginal tear. (I watched some of the repair and would have considered it a second degree.) Even with all the manipulations and forceps, she never did have a perineal tear. What a testament to mom’s nutrition and tissue integrity!

The baby was wrapped like a burrito and brought to mom – did she unwrap her and put her skin to skin again? I can’t recall, but all of us were giddy with joy and I was oh so happy for the VBAC and the doctor was sewing and mom was happy and the baby was fine and there was still no one there from Peds or the NICU. Grandma was talking delightedly, dad was sweating and thrilled – and I sat in the chair and cried for a few minutes… tears of relief and release. I just needed to cry.

Mom asked if the placenta was out and the doc said it sure was, it had come out at 5:45pm… the birth, we learned, was at 5:40pm.

6 hours and 25 minutes of pushing.

Do I count it like that? Or do I count it from when she was complete in the hospital? If I were at all inexperienced with vaginal exams, I would question what I felt while we were still at home, but I know what I felt – I know she was complete and then not complete. I know she was pushing from before noon. I wrote in her chart that she pushed for 6 hours and 25 minutes. She deserved every second of that time charted and acknowledged.

Amusingly, when we got to the hospital, the doctor made comments about the baby coming fast… that mom had been 8 and then complete in a very short time. When we talked about labor really kicking in about 4am, she said that was still really great for a first time vaginal birth. We all kind of looked at each other and I wanted to blurt out how long she really had been pushing, but I kept my mouth shut and let her believe what she needed to believe.

We were all so tired. I’d not napped at all in the 15 hours or so of active labor and immediate postpartum period. Dad wanted to go get the girls, so he and I headed off about an hour after the birth. I still needed to go home, to their home, and clean it up from looking like a birth room. Oh, to have an assistant!

As a midwife, I have always worked with an assistant, usually another Licensed Midwife. When I knew I was going to New Orleans, it was one aspect of the trip that was cause for concern. My client had just the doula that we could tap into, but she’d only been to 10 births. While mom was an RN, she wasn’t an OB RN. She was game for listening to heart tones, though, but I never had a chance to teach anyone how to listen because I remained awake the whole time.

Being sick, I’d explained to mom and the family that there simply are times when I would need to sleep. They all knew this and it wasn’t a problem at all. Until labor. When I would try to go into the living room, even for an hour’s nap between listening to heart tones, I couldn’t get anywhere near sleep before someone came into the room and looked at me with frantic eyes and I knew I was needed once again in the birth room. Dad, trapped under mom, tried to sleep in-between contractions, but didn’t get much sleep either. No one but the doula and the dogs had a nap.

When I arrived, I tried to see if we might find another midwife so I could tag team as I am used to doing at births. It didn’t seem palatable to mom and the one midwife lived very far away. I never did call her. I simply thought about all the midwives who work alone and thought if I needed help, we’d just get our butts to the hospital. It’s the same as my not having oxygen – it was the first birth I attended ever without oxygen. Well, the birth did have oxygen; it was the labor that didn’t have any present. I figured, again, if we needed oxygen, then we were off and running to the hospital.

Remember my list I wrote of things to take to a remote birth site? Those are the things I had at this birth. Now you can look at my supplies through knowing eyes.

When dad and I were on our way home, mom called and said the baby latched on with a delicious slurp and hadn’t let go yet. Dad was so excited and tired, he almost ran into a car in front of us twice. I had to grab his arm to pull him from his reverie to stomp on the brake!

Once back to their house, I cranked the air, turned on the fans and cleaned up the birth supplies. I put my things away, sat and charted, changed the bed, started a load of laundry, washed the dishes and then took a shower and went to bed out in the RV I was staying in. And I slept.

Mom came home 2 days later (she would have come home the next day, but her leg was some numb from a tweaked femoral nerve).

At a week postpartum, she remains happy with the experience, still somewhat in disbelief at it all. Dad is happy… glad we went to the hospital finally. He said it was so difficult enduring his wife’s increasing pain. I told her I never really saw her as in pain, but just in kick-ass labor. She said she could have gone without the epidural just fine if it hadn’t been for the horrid three-point stabbing going on. Of course, with all the genital manipulations, it was a darn good thing she did have an epidural in place! Grandma is also very happy and so glad it turned out the polar opposite of the last birth experience. Mom worked so hard to create a birth team that supported her belief in a VBAC. I was so honored to be a part of that team.

She had her VBAC. Yes, she had her VBAC.

The baby weighed 7 pounds 7 ounces. So much for not birthing anything bigger than 6.5 pounds. I told her she should send the old OB a birth announcement with both mom and baby sticking their tongues out. While she won’t be doing that, she is going to send her a VBAC birth announcement.

She had her VBAC.

I am so proud.