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.