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.

Wednesday, June 14, 2006

The Story (a homebirth)

I gathered up my apprentice and assistant and we presented at my client's doorstep at 5:55am. The household was up, but stumbling around - mom was in the shower. We chatted briefly about what happens if there is an emergency as I broke the water (dad brought it up) and I talked about 911 versus taking the car... and where we would go (a local hospital where her SIL is an L&D nurse). I asked if there was any reason in particular he felt we should talk about it and he said he just wanted to be prepared.

Mom came down and we did a few minutes of listening to the baby, doing vitals, and talking about how this was the last tool I had in my arsenal towards bringing on labor - the next step was the hospital. Mom and dad knew that and as we discussed the risks of rupturing membranes, they said they were ready for it.

We went upstairs and I did a vaginal exam and found the mom at 5cm, the baby LOA and 80% effaced.

Hmmm.

Actually, later that day, I realized she was really 100% effaced and had been from two days earlier. See, the cervix had an inner and an outer part and the inner was 100%, the outer was 80%. I would never have realized that if I hadn't done a vaginal exam during pushing and felt she was complete, but had that 20% puffiness still there. It was then I realized she had actually been 100% for the last couple of days. I'd even said to the assistant that it felt 100% inside, but I was taught to only go by the outer band. This time, the inner band was the true story.

At 6:57am, I broke her water with an amnio-hook. I tried to "catch" the bag on the right side of the baby's head (my right), but was too close to her head and her heart rate went down some, so I moved over to the left side where there was more water bulging. I snagged it after a couple of tries and the wonderful fluid was clear and beautiful. Plenty of it! I kept my hand inside as she coughed and laughed and water squirted out with every pressure move. We continued listening to heart tones throughout and the baby was great throughout. We had mom sit and then stand up, listened to the baby. Perfect!

Within 10 minutes, mom began contractions. Yay!

The apprentice and assistant and I went to IHOP for breakfast with the admonition to call us for anything - we were 5 minutes away. Mom ate some eggs and toast, too. We were excited sitting in IHOP - today?

When we got back, mom was in the tub (already?!) and contractions were 2 minutes apart and lasting for 90-120 seconds. Oh, my!!! Starting in transition, wasn't she!

She asked us to stop with the flash photography, so I put my camera away. She was just so beautiful! Her sister loved on her throughout the labor and helped her whenever she needed it (she's a therapist). We'd already set up several days earlier, so all we needed to do was be with the mom.

Mom told me she didn't think she could do this without an epidural. She just really thought she needed one. Knowing how fast she was going, I told her she couldn't get in the car, get in the hospital and get an epidural before the baby was born. She made some noise about it again (kvetching) and I asked her if she thought she could do these contractions in the car. She never uttered a word about leaving again.

Contractions were so fast and so close together and so long, I was always delighted her baby was happily galloping along inside.

Near when we got back from IHOP, the family was deciding who to call when. I told them whomever wanted to be at the birth needed to get there as soon as possible. I don't think they expected it to go so quickly because she'd labored for 20+ hours last time. As the family assembled, I only had to ask that people be more quiet a couple of times; the excitement was palpable!

At one point, several people were standing and I asked them to sit or squat down. Mom, lying in the tub, needed to be the highest point in the room. It was disconcerting having so many people towering over and staring at mom. I promised the aunt with the camera I would let her know when the baby was coming so she could stand up. I thought I made her angry, but later she said not at all. I felt I owed her a belated explanation anyway.

Mom began pushing and within a few contractions we could see what we all thought was head. However, it was white and I became puzzled as the heart tones were fabulous. One doesn't get a ghost-white head with heart tones like that. Mom felt inside and said the baby was "right there," but the only thing I saw was her ruggae bulging from her upper vagina (not a cystocele). I asked again about 20 minutes later and she said, "right there!" showing me the baby was a fingernail's length inside. I didn't think so, so asked if I could feel. She said it was fine, so I went in and found the baby at a +1. Much higher than she thought.

She'd been grunting, but not really pushing pushing. I waited for the urge to become overwhelming - her family tried to count and push her head down chin to chest - but I explained quickly, she was doing great - let's just listen to her.

Within another few contractions, the urge hit and hit good and I could really see the baby's head starting to peek out of her vagina. It wasn't white.

Dad had been in the tub - sitting on the ledge - but was very uncomfortable sitting there (and not just physically), so took one towel and then later, another towel and made a cushioned seat for himself. He wiggled and stood and sat and shifted his feet over and over until mom finally said, "if you want to get out you can." "I can?!?" and he jumped out and cleaned his legs off. (There were floaties in the pool - I think that was what made him most uncomfortable. The floaties were leftovers from castor oil, so not too fish net-able.)

As the head started to be born, it kept coming - and coming - and coming. She was in the water and the baby seemed to get hung up on the cheeks. When movement stopped, I hopped in the water and touched the head to see what the deal was - was there a cord somewhere I couldn't see? Is that what I feel? Nope, that's an ear. She began pushing again, harder and the nose came out and then the lips and finally the chin. Anticipating a shoulder dystocia, I encouraged mom to push good to get the baby out. She did not rotate except slightly and my assistant called out 30 seconds. I had mom stand and put her leg on the edge of the tub to no avail. 45 seconds. I told mom we were getting out, praying that the lifting over the tub would dislodge the shoulder, but it didn't.

I had mom lunge again, but she needed help, so we put her foot on the tub. No baby. McRoberts time. I asked her to get onto her back and the my assistant and her sister pressed down on the soles of her feet to open her pelvis WIDE. I pressed on the baby's head (body - not just the head or just the neck) with each change of position, but she didn't budge. In McRoberts, she remained wedged and my assistant called out 1 minute 30 seconds.

The baby's head began looking like a grape by the time we were climbing out of the tub Now, her head was nearly black from suffusion. I had a fleeting thought of a dead baby, but continued doing what I knew to do to free this child from inside its mother.

Finally, FINALLY, there was movement and the baby oozed out of her mother very slowly, trailing a huge amount of meconium she had just released during this experience. We left the cord pulsating for at least 2 more minutes (mom needed blood work done because she was RH negative, so we need to cut a tad earlier than usual to make sure we get enough blood for the test).

The baby girl lay motionless on the floor next to mom. Mom started crying as we grabbed the bag and mask, but it seemed stimulation might be all she needed. Thank god! We rustled her up and her heart rate was wonderful, but when we stopped annoying her, her heart rate went down to under 100. When she opened her eyes at about 30 seconds postpartum, I could breath a sigh of relief as we continued rustling her. She took her first breath at about 50-55 seconds. Her 1 min Apgar was a 3.

Blessedly, she was in primary apnea and she came around with stimulation. In secondary apnea, the only way to bring a baby around is with resuscitation. Everyone who does this work assumes the baby is in secondary apnea because you cannot waste time stimulating if the bag and mask is more appropriate. Happily, this baby showed signs of annoyance long before she opened her eyes or took a breath - small grimaces let me know she was "there."

Her short cord didn't allow for her to be on mom in the position she was in, so once the baby started crying crying (not just breathy squaks), we moved her back down and between mom's legs up onto her belly. The room was crying - me included.

5 min. Apgar was 7.

A separation gush let me know the placenta was ready to be born. Is that too much blood for a gush? sigh Of course, the adrenalin rush in mom didn't help the open blood vessel issue at all. Even though we all stayed calm and quiet, she got that it was urgent. I wanted to see where that bleeding was coming from and asked her to push the placenta out. I assisted its birth (thank god - again - that I know how to do this action) and the placenta came out Duncan. Ah, now that explains why there was bleeding! Another gush and I gave her a shot of pitocin and the bleeding subsided. (Mom is a freckled red-head.)

As the placenta was being born, the membranes trailed and as I began turning the placenta around to whirl it out of her vagina, her cervix poked out to say hello. Blinking, I called the assistant to look and removed the rest of the membranes easily. The cervix, deep purple and red, was already closed down to about a centimeter (looking just like my cervix flower picture!) and was still inside the vagina, but right at the introitus. I put my fingers on the side and said, "Let's put you back where you belong," - mom eep'd and I apologized. I told her in private what had happened and told her if she felt it while wiping, that's what it was and it should recede within a couple of days. We gave her sepia (a homeopathic) and the recession seemed complete by 3 hours postpartum. Hurrah!

We cleaned mom up some and then she walked to the bed while dad held the baby. She got situated in the bed and her baby was handed to her again, naked and HUGE. As soon as she was born, I said she was over ten pounds. Looking at her again, I shook my head at her size.

Asking if we could weigh her soon, mom and dad also wanted to know, so my apprentice grabbed the scale (a fish scale) and we weighed the baby: 10 pounds 8 ounces. Whee-Ha!

Her face was still diffused and we found a long bruise on her upper right arm (going over a bone or two?) so I asked if I could give the baby a Vitamin K shot- mom agreed and I gave her one. She never even flinched.

For a variety of private reasons, mom was going to mix formula and breastfeeding and had bottles close by. Because of her size, I encouraged mom to feed the baby sooner than later. She had tachypnea (breathing fast) and hypoglycemia can send a baby into full respiratory distress quickly and dangerously. She fed the baby a bottle about 20 minutes after the birth and she drank 2 ounces in moments! Mom put her to the breast after that and she was absolutely in bliss. Respirations slowed and all was well.

The baby's temp was some high for awhile, but removing clothes and such resolved it. I worry when there is TTN (transient tachypnea of the newborn) mixed with another sign of distress such as a fever - indications of possible infection), but she settled with nursing and removing clothes helped with the temperature.

Mom had another bout of bleeding that raised our eyebrows, so we gave her another shot of pitocin. It seemed to have done the trick. Finally.

I knew mom needed to be sutured and she didn't care. My apprentice went out to the car to get Anne Frye's suturing manual and I told mom not to be concerned that I was studying before the job because "I always bring this along" which is true, but I don't usually open it! This time, I was ready! I didn't even break a sweat this time suturing... wasn't nervous at all. My assistant was my suture doula and helped me piece the vagina back together visually as well as coaching me while we were going. The advanced suturing class she just did paid off wonderfully!

The tear was a deep first degree and looked like a Y with the inner labia being the V-shape and the leg of the Y inside the vagina, but not terribly deep. For the first time, I didn't get all namby-pamby about exploring the vagina, either. I apologized, asked her to tell me if I needed to stop and then went in when she was ready and did the job I was hired to do.

I explored the posterior fornix which felt like it had blood pooling there, but I didn't feel any pumpers and when I sopped it up with a gauze "tampon," it stopped bleeding as much. I found two skid marks in her upper labia, but those didn't need repairing.

I put some arnica gel on the areas I was going to suture and then injected lidocaine the way Anne Frye recommends... tiny pokes with minimal solution being injected in the tissues to keep swelling at bay. It worked! She didn't feel the suturing except right at the end and only at the upper labia area for one stitch. She had a couple of varicosities I had to dodge, but did that just fine, too.

The next day, my assistant and apprentice (who did the 24-hour postpartum visit because I was in New Orleans) said you could hardly tell she had even been sutured! They said the swelling was gone and her vulva looked perfect. Mom checked herself out in the mirror and was very happy with my suturing job. I'm beaming. See me?

One thing seems to be a skin tag might be near the edge of one of the sutured areas. The suture doula pointed out that I needed to pull it up and I tried, but it didn't stay there. She told mom yesterday a doctor can slice it off at 6 weeks postpartum, but I don't know if she told her that most tags like that shrink so well you can't even see them anymore. Let's hope this one is like that.

The apprentice and assistant cleaned up the room, mom's family cleaned the bathroom (we'd made some mess what with jumping out of a tub to deliver a baby and then having some bleeding and delivering a placenta) and then I did the newborn exam (about 2.5 hours postpartum).

We stayed for just shy of 4 hours postpartum and took our leave gleefully and thankful to the Universe that lets babies live even when they have a hard start.

The question comes up about why so many shoulder dystocias... especially, why do I get so many shoulder dystocias? I wish I knew why I got so many. I honestly believe it isn't a "to think is to create" issue, but perhaps babies are getting so big, there is no way I couldn't get a shoulder dystocia now and again.

You know how some photographers specialize in wedding photography? Others specialize in kids or pets? Well, as a midwife, I specialize in shoulder dystocias. Other midwives I know specialize in hemorrhages or twins or breeches. Sometimes, there is just a special skill we possess - and who knows why. I sure don't. Why do some lawyers become pro-bono altruistic attorneys and others represent OJ Simpson? Why do doctors specialize? Because something resonates inside them.

From early on, I have seen and known what to do about shoulder dystocias. I think it is so frightening for so many, I took a special interest in handling it quickly, smoothly and correctly. There is no room for error - no time for bringing in an Anne Frye book and having a shoulder dystocia doula. It is me and me. Assistants help sometimes, but generally, it is me.

I joked that perhaps my midwifery services should come with a shoulder dystocia disclaimer, but isn't that setting them up for it?

My premonition (intuition is what another reader called it) didn't play out the same way as it really happened. I saw no success in the resuscitation. I did not even see a shoulder dystocia or a big ol' baby. But, I was ready. I feel I was no less ready than any other time, though.

In the Yay Is Me vein, the family was so grateful and kind about the whole experience. We all knew what would happen in the hospital had the same thing occurred. A circus of loud proportions is how they are handled in the medical world. Blech. Mom, while knowing things were serious, didn't quite get how serious until hours after the event. I'm so glad!

She said she knew when I jumped in the water, something was up... and when I told her to stand and lunge and get out of the pool and lie down... something was REALLY up because she knows I direct women virtually never - never, certainly, without reason. She was a delight and did exactly what I needed her to do when I needed her to do it. She said that was the trust she had in me - that she knew if I asked for something, it was for good reason. The trust on my end came from doing the birth at home in the first place and then believing if she needed to do something for her own health and safety or her baby's health and safety, she would do it. And she did!

While I merely did what I was trained to do, I am very proud of myself. Instead of gloating with the family applauding, I turn as much as I can on the mom, thanking her so much for believing in me, for moving where she needed to, for talking to her baby, for growing a healthy baby, etc. Pride, while okay for a flash of a moment, has a way of coming back to haunt you.

Now I sit in New Orleans, waiting for this mama to deliver... waiting patiently. I am enjoying myself immensely. Lots of time to read blogs, sleep, write, sleep, and spend time with myself. Her family is a delight - it's going to be a good birth (a VBAC).