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.


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).

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