Friday, May 19, 2006

Hospital Birth

went to bed at 10pm and was awakened at 11:30pm to dad telling me mom was working hard with contractions and had been since 9:30pm or so. I told him to come on down the mountain – about 90 minutes from my house.

My family went into overdrive, doing last minute cleaning, readying, and making sure the hot tub was at a decent temp (we initially had it set for 100, lowered it later when the baby let us know 100 was a tad too high). I tried to sleep, but that wasn’t going to happen.

At 1:00am, mom and dad got there, mom in pretty good spirits, but working. I didn’t do an exam. I called the other midwives/apprentices at 1:30am to give them a head’s up, but to tell them things weren’t really cooking yet, so they all asked if they could sleep longer. I said, “Sure, I’ll call later,” so I got off the phone and tended to my mama.

Wandering through the house, we laughed and talked and spent time with each other… everyone in the house was awake except my daughter who, miraculously, slept through it all.

Our puppy was the hit of the labor… squealing, hopping around, delighting all of us at his antics. Luckily, this mom loves dogs, so neither dog had to be corralled until later in labor.

This mom had the Going Into Labor Chicken Parmesan at Olive Garden (for those looking for the natural route to provoking labor, this works loads) earlier in the evening, but barfed it on the way to my house. She wouldn’t eat anything and it annoyed the crap out of me. I finally, FINALLY got her to sip some Propel, but she only took two bites out of the whole grain bagel with peanut butter. Frustrating. She did sip some water, but not nearly as much as I thought she should have been taking in.

Things seemed to pick up nicely, so I called the others to come over about 5:30am and they came willingly and cheerfully.

Mom loved spending time in the spa. She couldn’t wait to get in and hated getting out a couple of hours later when the baby’s heart rate was up to 190 (eek!). We turned the spa down to 98 and when she got in later, the baby liked that much better.

I’d never seen mom naked until the moment she disrobed to climb into the spa. It was then I saw her pendulous belly and thought, “hmmm.” Primips don’t usually have a pendulous abdomen.

Contractions were off and on strong, frequent, slowing, sharp, dull, and then absent. Malposition/malpresentation was definitely a consideration.

Mom went to lie down for awhile and I got about 2 hours of sleep, waking each hour to listen to the baby’s heart tones. They were wonderful.

When mom awoke, she still didn’t want to eat, but after some walking, wanted to get back in the hot tub. She got in and after a couple of hours, as dawn was turning into broad daylight, she began pushing. I’d done one vaginal exam before the others came and she was 5-6 cm. I did another exam at 9:30am because pushing wasn’t productive (mom couldn’t feel anything at all in her vagina and the contractions were odd… 30 seconds long, 6 minutes between… we waited to see if she just needed to rest, but I knew she needed food and some help with positioning).

She loved being on her hands and knees in the hot tub, loved semi-squatting in there, too. In the house, she was on hands and knees. Knowing what I know now, those were the absolute worst positions for her. I should have bound her belly a dozen hours before we finally did it.

The exam at 9:30am, after a couple of hours of pushing, showed she was 7-8 cm. Pushing needed to cease. Her cervix was really soft and buttery, stretchy, too, but not so stretchy as to allow the head to slide through. Just the suggestion of not pushing was enough to slow her down. She’d been pushing in her head as it was… I told her several times I was worried about her teeth breaking off because she was pushing in her mouth instead of her bottom. I’m sure the real urge to push not even being there brought the I’ve-Got-To-Push action right into her jaws.

Somewhere around 11am, mom got out of the tub and went to the bed to rest. I was dozing on the couch on my partner’s lap and had the most vivid thoughts about this birth.

I saw myself catching the baby and he came out grey and completely floppy. The cord was flaccid. The baby didn’t breathe. I watched from my dream place and thought, “oh, no… we aren’t supposed to be here.” I knew if we weren’t at the house, then that scenario couldn’t play itself out because I wouldn’t be catching.

While I dozed, the two apprentices were doula-ing the mom and came out and said she was so discouraged and tired, she didn’t know what to do. I went into the room and within moments could see she was waning fast. Whenever she sat up, her face drained of blood and I was so worried she would faint. She still refused to eat, didn’t want an IV, but when I offered her the options and included the hospital, asking if it was time to go, she said that it was time.

This was 1:30pm.The other midwife and her apprentice stayed behind to clean up and my family cleaned everything else. By the time I got home, the hot tub had been emptied, sterilized and re-filled with a new filter in place. Damn she’s good!

We got to the hospital about 2:30pm and went right into the birth center. I parked the car and was going quickly up to the birth center, but a gaggle of interns in black suits were lolli-gagging their way into an elevator and I had to nearly scream, “I’ve got a baby coming out! Move with a purpose, PLEASE!” They got their asses moving after that.

A midwife I know was on duty and I was delighted about that. A wonderful, wonderful nurse was ours – she’d been a childbirth educator 40 years ago and taught the midwife I work with a lot how to doula 20 years ago. She also had a lot of home birth experience in her life. We were so, so fortunate.

An IV was started and antibiotics started. The CNM asked to do an exam and mom said okay. She was 7-8cm.

Still.

Ohhhhh, she was not happy. So, options were discussed… she was asking for help… isn’t there something she can have and still stay in the birth center? Nubaine and Phenargan were administered and mom slept for 2.5 hours. I went to the family room and my apprentice brought me a blanket and pillow and I crashed for 2 hours… hard and fast.

It’s hard to be “up” this long for me. Not always feeling so well, I take pains to stay calm and as healthy as possible, but it’s been a long, long while since I have had to be awake and working so long. Blessedly, those around me, clients included, understand and allow me to rest when I need to. When they need me, my adrenaline zips right to where I need it to so I can take care of my clients. (I certainly have had thoughts of stopping/slowing, wondering if I am giving my clients all they deserve, but I keep being told it is worth the small moments in time I am not present so I can rest. So I keep going.)

When I awoke, mom had been examined again and had a cervical lip. A new CNM was there because the birth center was full and many CNM clients had to be moved down to L&D for a variety of reasons. This new CNM was someone I hadn’t ever met before and I had the feeling she wasn’t too thrilled to see an LM, ER Nurse, doula/apprentice and dad flanking the woman in labor (who is also a doula!).

Within moments, though, she warmed as I offered to help her however I could. Because of all the commotion, I was allowed to take a lot of “control” over the mom’s care. I kept the doppler near me and took heart tones, reporting to the nurse as she charted when she was in the room.

My apprentice is a doula at this hospital, so knew her way around… got us pillows, bean bags, juices, water, ice, blankets, towels, the birth ball… all things to help mom be more comfortable.

Mom was up pushing on the toilet, hands and knees, on her side, in the chair, and standing. Her water broke spontaneously and there was thin meconium. Later, during an exam, there was forebag the CNM removed. More thin mec.

When she was lying in the bed, I looked at her belly and it looked exactly like a posterior baby belly… a slope up above the umbilicus, a dip at the belly button, and a slope again below the umbilicus. I went and talked to the RN, telling her how concerned I was about the pendulous abdomen and my belief that it was keeping labor from being as productive as it could be. She agreed and went and found me a binder.

Mom’s contractions had once again petered out… every 7-10 minutes, lasting 20-30 seconds. One nurse said it wasn’t uncommon to have them do that right before pushing and I explained that she’d been complete for at least a few hours. Oh, different story.

We put the binder on and within moments contractions picked up… every 2-3 minutes, lasting 60 seconds. A huge difference!

After an hour, mom just couldn’t do any more. The contractions had stopped again and she was so discouraged. Asking what her options were, I laid them out.

1. She could go down to L&D and have an epidural with pitocin

2. She could go down to L&D and have pitocin

3. She could go down to L&D and have pitocin with possible vacuum extraction

There simply wasn’t much else to do in the birth center. Luckily, we’d still have CNM care down there, but she’d have to have continuous monitoring. She accepted that reality with grace.

This mom, after weeks and weeks of whining, was so amazingly stoic and brave during her labor. I was more than impressed and told her so about 80,000 times. She never whined, merely demonstrated her exhaustion and frustration. She winced, but didn’t scream or cry (not that those are a bad thing). She was so different in her labor compared to her life, I was so, so proud of her.

She went down to L&D on a gurney and I went down after dumping my stuff with one of the relatives in the waiting room.

I was in the hall, walking towards the room and I could hear a nurse screaming at my client to PUSH!! PUSH!! and she was counting so loudly, as if my client was stone deaf. I grabbed the new new midwife (another one I didn’t know before that moment) and told her to please tell the nurse to stop shouting at my client. We went in and that bitch nurse was trying to get my client to grab the handle when she didn’t want to… the nurse pulled her hand off the bed rail and pushed it to the handle, all while yelling that she needed to draw PIH labs (her BP was rising… no wonder why!). She then began yelling at her again to PUSH, but didn’t count and I stepped next to her and looked her right in the face and said, “You have GOT to stop yelling at her. She doesn’t need to be yelled at.” The nurse was stunned, spun around and snorted before leaving the room, never to return.

Instead, we got a marvelous, wondrous, beautiful traveling nurse that was so supportive and loving – along with the CNM – that the time in L&D was nothing like it could have been.

I asked for a birth bar so mom could leverage her feet on the bar and we threw a sheet over the bar so she could use it to pull as she pushed and the difference for her was great. As tired as she was, she showed amazing strength pulling and pushing. We’d gotten down to L&D at about 7:30-8:00pm and because she was doing well, the monitors were unstrapped and no pitocin was started at all. She already had the saline lock for the antibiotics every 4 hours and they did put some Lactated Ringers in her for some energy, but they were extremely casual about the typical L&D freak out issues.

Right as I met the last CNM we worked with, she smilingly asked if I wanted to catch. Blinking, I was pretty shocked she would say that, even though the earlier two had asked the same thing. I mean, now we’re down in L&D! I told her I would be delighted to catch, but to let me know what I could do to help her. She said, “have a great birth.”

As mom pushed actively, I sat at the bottom of the bed helping her with focus and not to clench her teeth out of her mouth. She really didn’t have the hang of where to push at all and no amount of telling her was helping. I touched her vulva with cool washcloths (she was getting swollen and had some varicosities developing) and tried to direct the pushing there, but it wasn’t much help at all.

Throughout the labor, I made mom laugh about different things and here at the foot of her bed, I was being a little silly and making everyone laugh. After hours and hours of maybe 5 words an hour, this mom, in complete coherence, looked me in the eye and said, “I need help. I don’t think I can do anymore. Please help me.”

I stopped the humorous words and looked her in the eyes and told her she could do it, that she could take all the energy she wanted from all of us in the room… that we loved her so much and we all had plenty for her to take, but that she was so close (we could see about a quarter of the head peeking through).

With the next contraction, I encouraged her to reach down and touch the baby’s head so she could find some inspiration.

Mom reached down with her left hand and something miraculous happened! Whereas she had been pushing with all her guts (no one yelling at her at all, or even directing her pushing, but the wonderful nurse in her ear, talking her through it all) and making very, very little progress, when her hand touched her baby’s head, she barely had to sigh to have the head advance. I loved it! She would be holding the head and her baby slid out very, very slowly. If she moved her hand, she tried pushing and had zero progress. My job was to remind her to touch her child and eventually helped to support her perineum, but no pulling, tugging, or anything invasive.

Because the head was being born so, so slowly, I watched the CNM thinking like I was and she stepped up onto the bed over the mom in case of a shoulder dystocia. I looked up at her and she said, “just in case.” I nodded knowing exactly what she meant.

As the head was born, there was very little restitution, but as he started to turn slightly, I utilized the skill I learned ages ago of helping to birth the baby before the shoulders get caught behind the pubic bone. Pressing down on the shoulder to get the anterior shoulder born and then pressure up to birth the posterior shoulder, I felt for a cord and didn’t feel one, but as his anterior shoulder was being born, there was a cord… absolutely limp and flaccid. I looped it over his head and put him up onto mom’s belly with her hands helping. (I’ve since apologized to mama for pressing her child’s body like that, but it was the right thing to do at the moment… I also told her I’d pay for a cranial sacral/chiro appointment for him.)

He was born at 11:32pm. That comes out to about 6 hours of pushing if we were medically counting.

The baby boy was on mama’s belly and we looked and there was a HUGE blob of meconium on the bed, his body covered in mec. The cord so limp, the baby so limp, too. Stimulation did nothing and the nurse said, “Cut” and the CNM was right there, cutting the cord. The nurse and CNM took the baby to the warmer and told me to call NICU. I did and talked to mom, watching her bleeding. I told her she cannot bleed. I told the nurse and midwife I was watching the placenta and bleeding while they began working on the baby.

His heart rate was 100, but there was no respiratory effort, color, grimace, or tone. By one minute, there was a tiny bit of tone and he was gasping, so he got a 3 for his one minute Apgar.

NICU didn’t get there fast enough, so I called again and asked for NICU Stat and they said they were on their way.

I cleared the inlaws out of the room to make space for the multitude about to converge on the baby, asking my apprentice to leave, too, but she was trapped behind the delivery table (and I was glad so she could watch all that was happening).

Dad was next to the baby, touching him… no one ever asked him to move, leave, nothing… they suctioned the baby and got gobs and gobs of thick mec out of him. He was gasping and had serious tachypnea (respirations were 100-120), retractions, flaring, and grunting. The neonatologist stood with her hands across her chest as she directed, calmly and kindly, the actions they needed to do to this boy. At one point, dad turned to me and said, “he’s doing great! he’s breathing!” and I turned to mom and explained that gasping wasn’t breathing. She nodded her understanding.

They brought the boy to mom for a quick kiss and he was whisked off to the NICU where, it was learned later, that he had meconium aspiration. He was, of course, tested for a variety of illnesses, including GBS, but those all turned out negative.

The baby, at 3 days old, came out of NICU and nursed for the first time today (while still in the NICU); nursing is going well, thank goodness!

Mom had no tears, the placenta was born and was incredibly stained by the meconium. The amnion, chorion, and cord were all deep greenish-yellow. The baby had been sitting in the poop for at least 6-8 hours prior to birth. It was then apparent that his aspiration occurred before birth, not during or after the birth. When I knew I was going to catch, I asked the midwife about the meconium and she said since it was thin, she was fine with wiping, so that’s all I did was wipe his face gently. There was very little mec on his face, but his body was muddied with it.

He had a caput that was about 2 inches across and 2 inches tall… a cork keeping the meconium from oozing out to let us know there was going to be an issue.

The baby’s heart rate throughout labor in the hospital was 140s to 150s… perfectly fine. The heart rate less than a minute before the birth was 140. At birth, this dead-looking baby was born… the exact image I’d had 12 hours earlier. I never, never would have expected to catch in the hospital and have that premonition play out as it did, but there it was. Scary as hell.

In working through this with my apprentice, I explained how hard it is to share the reality of why birth workers sit in anticipation of just such circumstances. We sound like doomsday creators, naysayers, scaremongers… when we talk about how really, really the heart rate can be fantastic less than a minute before birth and how it can be zero at the birth and the baby need amazing amounts of help to get started. She, deeply steeped in the UC community, said the UC women would never believe what she saw. I suspect they would think she is being brainwashed, not that she is objective observer. How can the information get out there without making disbelievers close their minds even more? I’m just not sure.

We don’t sit in panic expecting something bad to happen, but readiness is vital. We really do never know what will come out of the experience we are in the middle of.

One more thing. Not sure why, but this mom’s vagina was interesting… different from most. The entroitus was far, far back from where it is with most women. She had virtually no perineum, no inner labia, very thin outer labia that was nearly flush with her thigh in some areas. When I did the first exam, I was trying to get inside her in the wrong place and I’m sure it hurt. I apologized profusely and asked her to show me where. I felt like a dork until the CNM did the same thing. I began telling whomever was going to do an exam about her anatomy and that made a huge difference. The midwives did tell me that her vulva/vagina were different from what we usually see. Again, not sure why, but very interesting.

Whew. I am tired.

Thank goodness the baby is alive and well. Mom is extremely happy.

3 comments:

ladyelms said...

I'm so glad I found this other link/blog of yours. This birth intrigued me when you first began talking about it, and reading your very detailed description of it has been very beneficial. This is hard for me to understand, however. You said: "The baby had been sitting in the poop for at least 6-8 hours prior to birth. It was then apparent that his aspiration occurred before birth, not during or after the birth." My brain is having a hard time making sense of this.

I've learned tremendously from your words and appreciate the graceful way in which you articulate and share your experiences and perspective. Your little corner on the web is an incredibly valuable resource for women like me.

Anonymous said...

Wow, such a well told story of a complicated birth. I was moved to tears. Thank you from a former doula
who now works with old folks!

Anonymous said...

*crying*
Thank you.