Belly Tales

Last night was a very strange night. It wasn’t that busy, and yet, somehow, neither the other midwife nor myself were able to take a break. The pace was very steady. We kept expecting it to settle down, but it never did. Just as we were thinking “oh, as soon as this woman is discharged, we’ll be able to rest for awhile”, then another woman would walk through the door.

There were two deliveries. One was a grand multip (G6P5005) who came in 9 centimeters dilated with a bulging bag of waters. The other midwife ruptured her membranes at 3:40 am and she delivered at 3:41 am. I love deliveries like that! It’s always amazing to me how QUICKLY a baby can actually exit the human body, when all the conditions are right. It’s as if they’re on a greased slide, and they just whizz on out. If only all births were so quick and easy.

The woman I delivered was 16 years old, having her first baby. She was newly immigrated, and the father of the baby was back in Santo Domingo. She had her mother and grandmother with her, though, and they were a tremendous support team for her as the contractions were picking up, fanning her face and feeding her ice chips. She progressed remarkably fast for a first baby. We forget, sometimes, that teenager’s bodies are meant to give birth, and probably more so at this age than at any other time in their lives. Even though they might not be emotionally ready, their bodies are, and they often open up through labor as if it were the easiest and most natural thing in the world. This girl was having a labor like that.

When I came on at the start of the night she was 4 centimeters dilated and in a lot of pain. We discussed her pain options, but she didn’t think she needed anything just yet, and carried on with the support from her family. Two hours later, she was ready for something for the pain, and was thinking that she wanted an epidural. However, when I checked her, she was a whopping 8 centimeters dilated, and the head had moved down to zero station. I told her she was a superstar, she was doing amazing work and the birth would be really, really soon. I told her that she could have an epidural if she really wanted one, but that by the time she got it she would probably be fully dilated and ready to push, and that an epidural would just slow down the birth in the long run. She didn’t believe me (I can’t really blame her….the contractions were pretty intense at this point), but her mother and grandmother exchanged a look, and both of them rolled up their sleeves. We coaxed her into a sitting position, and her grandmother went behind her, rubbing her back, while her mother continued to fan her face. Less than half an hour later, she was fully dilated (there is a Russian doctor at our hospital who likes to call this moment “fully delighted”), and was pushing beautifully.

The baby came down quickly and was delivered 11 minutes after she was fully: a beautiful little girl with a really tight nuchal cord which had to ultimately be clamped and cut in order to allow for the birth, and a compound right hand that extended as the baby delivered and unfortunately tore the girl’s left labia, leaving a tender, open gash. The pediatricians were there to check on the baby due to the moderate meconium which had been in her amniotic fluid, but the tracing had been overall reassuring (we’re calling this Category II now…has anyone else moved onto the new NICHD guidelines? Our hospital has finally made the switch officially, despite the fact that these guidelines have been around and endorsed by nearly everyone [ACOG, AMA, ACNM etc. etc.] since 1997, but I must admit, I’m still finding it a bit strange) and the baby came out vigorous and screaming, waving her little pink arms around. An altogether beautiful and uneventful labor and birth, which took less than 5 hours in total. You couldn’t have asked for a nicer first birth than that.

The eventful part came next, unfortunately. Everything was looking good. I was checking her perineum (intact! the only tear was the labial laceration) and waiting for the placenta when there was suddenly a pretty forceful gush of blood. I figured it was a sign that the placenta was starting to seperate, so I gave a gentle tug on the cord, and the placenta quickly began to descend. Instead of coming out with the shiny, fetal-side showing first (Shultz presentation) it came out maternal-side first (Duncan presentation) and I immediately noticed that the membranes had been completely sheared off on one side. There was a thick tendril of trailing membranes which were still firmly attached somewhere up in the uterus, and were taut and unmoving when I tried to gently tease them out by spinning the placenta a bit. Rather than tearing the membranes and losing them, I cut the placenta away and put a ring forceps on the trailing end of the membranes, so that at least we had them. I quickly inspected the placenta and saw that there were hardly any membranes present, only the cotelydons of the placenta, and the cord. Which meant that most of her membranes were still inside, either retained or trailing, I wasn’t sure which yet. And all the while she was gushing blood.

We moved pretty quickly. I called the attending doctor, we asked the family to step out a moment, and started the IV pitocin running. I gave fundal massage and felt absolutely no fundus! I couldn’t find it anywhere (later on, the attending pointed out that that is exactly what an atonic uterus feels like…as if there’s nothing there). The attending began to remove the rest of the membranes by traction, gently teasing and working them down. We administered methergine, then hemabate, and finally 1000 mcg of cytotec rectally. We started a second IV line and used a catheter to help quickly drain her bladder. I was doing firm fundal massage all this time, and finally, after what seemed like quite some time, but was really about 8 minutes, I began to feel a hard, firm fundus balling up under my hand, and the bleeding had slowed down to a trickle. The doctor had managed to extract what looked like the rest of the membranes, and his sonogram later confirmed that the uterus was empty. And then, just as quickly as it had started, the bleeding stopped. The total loss was estimated to be between 800 - 1000 cc. But once the trailing membranes were finally out, and the fundus was finally firm, she was absolutely fine. I repaired the labial laceration, cleaned her up, and helped her breastfeed her beautiful girl.

Her hemoglobin and hematocrit dropped pretty precitously when we checked her CBC four hours later, but it was still in the range of normal (10.0/ 30%), so in the end she didn’t need any kind of blood transfusion. In fact, I’m still kind of astounded by the entire thing. It’s as if a huge emergency had been averted, and yet, at the same time, it felt really routine. We drill our hemorrhage protocol pretty regularly on our unit. It was really nice to see that when push came to shove, we were able to go down the steps of the protocol one by one, and amazingly (or perhaps not), they worked just the way they were supposed to, and lo and behold, the bleeding stopped! Nobody panicked, the nurses were prepared, the doctor was calm. Everyone knew what they were supposed to do, and we just did it.

Afterwards I was waiting for the shaky post-adrenaline terror feeling that often comes after emergencies, but it never came. It made me think about how far I’ve come in my first year as a new midwife. A year ago, this would have probably left me crying or near tears, shaking in the chart room, totally freaked out. Instead, I finished the paperwork, checked her bleeding again (it was fine) and carried on with the rest of the non-stop night. I guess this is what midwives do. They don’t panick, and they stop the bleeding, and that’s that. It was just a hemorrhage kind of night.

Here’s a lovely birth story to share, my 99th delivery:

We were all expecting a big baby. Her estimated fetal weight from Leopold’s palpation was judged to be approximately 4500 gms. The baby felt huge: fat and happy, and we were all duly nervous, because her first baby was only 7.5 pounds. She wasn’t a large woman, either, but her pelvis felt incredibly roomy, so we were proceeding very carefully, watching closely, wondering if things would progress.

She had an epidural, but even with the epidural, everything was hurting her: her back, her legs, her vagina. With the assistance of her partner, we kept turning her side to side, sitting her up and lying her back down, trying to alleviate some of the pain through what limited position change is available when someone has an epidural. She had cold packs on her forehead and sacral massage. Even so, it wasn’t helping much. She began to feel a lot of rectal pressure and wanted to start to push, but she still had a small lip of cervix in front of the baby’s head, so we breathed with her through her contractions and tried to keep her from pushing. She was really unhappy with us at this point; who wants to breathe when they feel like pushing?? It’s the hardest thing in the world, and she really struggled with it.

The thing is, even though her cervix felt nice and soft, and we could possibly reduce the small lip of cervix in front of the baby’s head, we didn’t want to. With large babies, there’s a lot of danger involved in reducing an anterior lip and bringing someone to fully dilated when maybe they’re not supposed to be. Sometimes there’s a reason for a woman with a large baby not making it to fully dilated. Sometimes it’s a message to you that the baby is actually too large, and it’s a warning that should be heeded. So we let her body work on its own, without forcing it, and eventually, after over an hour of being at anterior lip, the last remaining, stubborn piece of her cervix finally disappeared.

Our concern, of course, was shoulder dystocia, which is without a doubt one of the most dangerous of all obstetric emergencies. With shoulder dystocia the head is delivered but the shoulders get stuck, and you have only minutes to get the baby out before he or she begins to rapidly decompensate on account of the severe cord compression that occurs. There’s a whole list of maneuvers that you’re supposed to work your way through: first you pull the legs back, which helps to widen the pelvic outlet, and then you apply suprapubic pressure, which helps to pop the baby’s shoulder under the pubic arch and get the baby out. If that doesn’t work, you move on to other maneuvers, like Wood’s Screw or the Gaskin Maneuver (named after our favorite midwife, Ina May). You reach your hand in and try to delivery the posterior arm. Even though it’s not the perineum that’s the problem, but actually the bones of the pelvis, an episiotomy is often cut in order to ensure that there’s enough room to get your hands in to maneuver (and in our sick society, if a lawsuit is ever being brought to court on account of a shoulder dystocia, apparently if you haven’t cut an episiotmy, it’s a huge strike against you, since cutting is part of the “standard of care”. I’m not sure that I agree with that, but on the other hand, in such emergencies, you do what you have to do). You empty the woman’s bladder. You pray. You try the maneuvers again if they didn’t work the first time. The clock ticks so slowly, so that miliseconds seem like eons and all you can do is stare at this stuck baby with a face that’s slowly turning more and more purple. Sometimes nothing works. Sometimes you need to break the baby’s collarbone or humerus in order to get the shoulder out. I’ve never had a true shoulder dystocia yet in my short career as a midiwife, but I’ve seen a terrible shoulder dystocia in my work as a nurse, and I’ve heard the stories. It’s no joke. It’s one of the scariest things you’ll ever have to deal with in this profession.

So we were nervous, and rightly so. But she was making slow progress, on her own. She began to push once she was fully dilated, but she was tired, and her effort wasn’t great. She lost her fighting spirit, and began to cry, asking for a cesarean, telling us that she couldn’t push any more, telling us she wanted to die. This is all pretty normal stuff for the pushing phase, at least among the women we take care of at our hospital, but it only served to make us even more nervous. The four P’s of labor are the Powers (contractions), the Pelvis, the Passenger (baby) and the Psyche. If any one of those P’s are missing, you’re in trouble, and staring at this huge baby waiting to be born with a mother who’s psyche wasn’t in the best place was very, very worry-making. There comes a point in the labor as the baby’s head is just beginning to peek into view when you can really get a sense of just how big the baby is. You can put a finger on the baby’s crown and then palpate the baby’s rump through the woman’s uterus, and get a true measure with your hands for the first time, and let me tell you….this baby was HUGE.

But she was making progress. Slow progress, but progress. The baby’s head began to come into view during pushes, then would tuck back in again in between contractions. This is called Turtling, and it’s a sign of impending shoulder dystocia, and when we saw this, we really began to wonder what in the world we were doing by encouraging this woman to push. Slowly, though, it became clear that the baby was moving down, and was starting to stay down, even in between contractions. We could still get our fingers in, and could still feel lots of room in the sides and the back of her pelvis, and little by little, she kept pushing the baby down. Soon enough (well, after over an hour of pushing), she began to crown.

I was catching the baby, and was gowned and gloved and ready, running through the shoulder dystocia maneuvers in my mind. The doctor was standing next to me, also gowned and gloved. We had the pediatricians in the room, waiting. The back up doctor was also in the room, plus another midwife and 3 nurses. We had a stool ready, in case someone needed to stand on it to apply suprapubic pressure. We had broken the bed so there was plenty of room to get in close to her perineum, if need be (of all my births so far, I’ve broken the bed on only two deliveries, just to give you an idea). And there we all were, waiting, sweating, watching and waiting.

The head emerged, and it was huge and fat, with these chubby cheeks and tons of hair. I didn’t cut, but instead gave perineal support and pulled the perineum down around the baby’s face as he crowned. And there he was, in all his glory. It looked like she had the head of a young toddler between her legs, that’s how big he was. I don’t know about the rest of the staff, but my heart dropped into my feet when I saw that head. Surely this was going to be a shoulder dystocia. Surely we were all in a lot of trouble.

I let the head restitute on its own without rushing it. The baby slowly turned into ROT, and I thought: well, might at least try to deliver the shoulders, just to see what happens. So I gently applied downward traction, little more, little more…and then, all of a sudden, there was the anterior shoulder!! Just like that. Just like a totally normal delivery. As soon as I saw the top of the anterior shoulder, I applied upward traction to delivery the posterior shoulder, and the shoulders were out. Getting the actual baby out required hooking a finger under each armpit and actually gently tugging the baby free, because this definitely wasn’t one of those births where the baby was just going to slide out. But the baby came quickly and easily, with hardly a pause between the delivery of the head and the delivery of the rest of the baby. He began to howl, wiggling both his arms and fingers (a good sign, indicating that there was no erb’s palsy going on), and we put the baby onto the mother’s stomach, and everyone just sort of stared in amazement.

He was enormous!! Guess how big….just guess. Much bigger than 4500 gms. He was actually 5150 gms. 11 pounds 5 ounces. The biggest baby I have ever delivered, and one of the biggest babies I have ever seen.

Delivered in a hospital, by a midwife, without the slightest whiff of shoulder dystocia. Oh, and one of the best parts: she didn’t tear, at all. Her perineum was intact. There was one nick which was bleeding, which required one stitch, and that was it. That was it!! Such a miraculous, miraculous birth.

Sometimes birth is not normal. Sometimes there really are complications and problems which need to be dealt with in a hospital setting. Sometimes a medical approach to birth is exactly what’s needed. Sometimes interventions during birth ARE lifesaving. Yesterday was a perfect example of that. I was helping to take care of a woman who was incredibly high risk and had the odds stacked against her in terms of her chance of having a normal, uncomplicated delivery. She was severely anemic, and had been throughout her pregnancy; and not just the usual anemia of pregnancy—no, this was a woman who had a hemoglobin of 6.5 at one point during her 3rd trimester, and a hematocrit of 19%. (To put that in perspective, bear in mind that normal is a Hemoglobin of 12-13 or greater, and a hematocrit of 32-33% or greater.) She had been seen by Hematology several times during her pregnancy and had had numerous anemia work-ups. It all pointed to iron-deficiency anemia, and she was taking iron replacement therapy, but there’s only so much that this can do. At one point during her pregnancy she had been offered a blood transfusion, which she had refused. When she was admitted, her hemoglobin was 7.8 and her hematocrit was 21%—numbers which didn’t demand an immediate transfusion, but which were very concerning given the fact that she was going to give birth, and giving birth means losing blood, and if you’re severely anemic you don’t really have any blood to lose. Our professor used to say that if a woman is severely anemic, she “can’t tolerate” a hemorrhage…which is what…a polite way of saying that she’ll die?

In addition to the severe anemia, she was also preeclamptic. Her baby had oligohydramnios, probably caused by the preeclampsia (unchecked hypertension and poor placental perfusion can lead to intrauterine growth restriction and oligohydramnios, both of which are not good signs). She had protein in her urine, was hyper-reflexive, and was starting to have toxic symptoms (blurry vision, headaches, visual changes, epigastric pain, edema). She was admitted for an induction of labor immediately on account of the oligohydramnios and preeclampsia. To my way of thinking, this was the right call. With preeclampsia, you don’t want a patient sitting around at home with skyrocketing blood pressure—it can lead to siezures if untreated, and the only cure is birth. Similarly, oligohydramnios indicates chronic, long-term insult to the baby, which sadly means that the womb is no longer the best environment for fetal well-being.

This was her second baby. Her cervix was 3 centimers dilated at the start of the induction, so rather than using a cervical ripening agent like cytotec or cervadil, pitocin was started instead. Because she was preeclamptic, she was also started on Magnesium Sulfate, which prevents preeclamptic seizures by causing systemic smooth muscle relaxation. Mag is an awful drug. It makes you weak and hot and sweaty, and it often complicates inductions because it’s hard to induce contractions when a woman is receiving a medication which is causing all of her muscles to relax. Pitocin and magnesium are always at odds with each other. I think a lot of preeclamptic inductions fail because of the magnesium.

Anyway, maybe it was because of the magnesium, maybe it was because her first labor was also a very long, drawn-out labor, but in any case, her progress was very slow. I admitted her on Friday, and she was still in labor when I came back 12 hours later, on Saturday. She hadn’t made much progress; she was only 4 centimeters dilated when the doctor checked her that morning, and was still 4 centimeters when the doctor checked again 3 hours later. Her bag of water was broken by the doctor, an intrauterine pressure catheter was inserted to measure the actual strength of the contractions, and the pitocin was duly increased. And increased, and increased. It got as high as 28 miliunits/min., which was as high as I’ve seen it in a long time. Her contractions were adequte (because of the IUPC, we were counting montivideo units, and yes, they were adequate), but they were always irregular. When I checked her again 3 hours after the IUPC had been placed, she was only 5 centimeters dilated, and it was a tight 5 (I was worried that I was being too generous, and that the doctor would come behind me and check her again and decide that she was still only 4 centimeters, that she hadn’t made any progress, and that she would therefore need a cesarean for failure to progress).

I was really worried about this woman and this baby. I was worried about a severe hemorrhage. She had so many risk factors leading up to it; she was on magnesium, which relaxes the uterus and makes postpartum uterine atony more likely. She had been on pitocin for almost 24 hours, which tires out the uterus and makes postpartum uterine atony more likely. And because she was severely anemic, she couldn’t hemorrhage. She had no blood to loose. I was worried that after another three hours of little or no progress, she would give birth by cesarean, which means that her blood loss would be at least 800 cc. She didn’t have 800 cc to lose.

At least the tracing was always reassuring. I’m sure that if, at any point the tracing had begun to look anything other than beautiful, there would have been an immediate cesarean. Her urine output was always good, her magnesium levels were always on target (never too high or too low), and all of the medications we were giving her seemed to be doing their jobs. The woman seemed to be taking everything in stride, as well. I was amazed by her strength. She never panicked, even when she first found out that she had preeclampsia and would need to be induced. She had an epidural and was comfortable. She slept for several hours at a time, as did the rest of her family (her partner and grandmother, both in their chairs with their mouths open, snoring). She asked a few questions here and there, but for the most part, she seemed to trust that things would be okay. She must have known something that I didn’t. I was worrying plenty for the both of us.

Three hours after my last exam, I was unsure of what to do. I didn’t want to check her again and have to be the one to discover that she was still only 5 centimetrs dilated, and then have to notify the doctor and watch the entire thing get written off as “failure to progress”. On the other hand, we’re supposed to round on the women we’re taking care of every 2 hours, and I was trying very hard to be on top of things; it was already an hour past when I was supposed to check her and write a note. I called my preceptor on the phone and discussed the situation with her. We decided to write a note on her well-being, lab values and fetal status, but defer the exam for another hour, if possible. I hung up the phone and walked to the room, only to discover that the doctor was already there, and had just checked her. She was fully dilated.

I didn’t even have time to marvel over how she’d managed to go from 5 centimeters to fully in 3 hours…not that this is an impossible thing at all (many 2nd time moms do the entire labor in 3 hours or less), but she had been making such slow progress, and her body was battling the magnesium every step of the way. I was so incredibly, pleasantly surprised! I barely had enough time to get my gloves on before the baby’s head was crowning. He wasn’t a very large baby. She pushed him out in 6 minutes, and he began to scream and wave his arms around. Her partner cut the cord. The pediatricians were there on account of the prolonged magnesium exposure in the baby, but everything was fine.

The placenta came out 4 minutes after the baby, and we began to massage her uterus immediately. It wasn’t firm right away, but it firmed up with massage. We ran 40 units of pitocin in 1 liter of IV fluid (we couldn’t give her methergine because her blood pressure was too high, since methergine can cause a stroke if given to hypertensive women) and…please, no heavy bleeding…please, no hemorrhage…please, let it stop….and it did. She lost blood, but a normal amount. She had a small, first degree laceration which we quickly repaired so that it wouldn’t bleed very much.

And that was it. All of those risk factors, all of those hurdles to overcome, and in spite of it all, a normal birth. Even with the doctor in the room. Even with multiple IV lines, and packed units of red blood cells ready and waiting in case she hemorrhaged. Even with an induction that lasted 28+ hours, and heavy medications competing against each other. Even with a midwife that was worried about so many things that could have potentially gone wrong, which didn’t. Even in high risk situations, with all sorts of complications, even with a prenatal course and labor which is anything but normal….normal birth can and does still occur.

Today I caught my 50th baby! She was born at 4:18 pm to a young woman from Puerto Rico who was absolutely thrilled and excited about her first pregnancy. She was an induction for postdates (per hospital policy, all women are induced if they’re still pregnant at 41 weeks); she’d actually had an incidence of preterm labor earlier in her pregnancy, but now, instead of the baby coming too soon, we had the opposite problem—a baby that didn’t want to leave. Because she was an induction, she was on pitocin, and because she was on pitocin, she pretty much had to stay in bed (again with the hospital protocols…). She was so strong and so tough, though, laboring in bed for the entire afternoon and refusing an epidural the entire time, through every single pitocin-induced, booming, more-intense-than-natural-labor contraction. The only thing she took for pain was a dose of stadol when she was around 5 cm dilated. I think her birth team made a big difference for her. Her mother and the father of the baby were at the bedside with her all afternoon, fanning her and bringing juice and ice water, putting cold packs on her head when she was hot, massaging her legs and arms. I couldn’t get over the father, in particular. He was such a young man (19 years old!), but his maturity was well beyond his years. He knew just when to be attentive, and just when to be quiet and not pester her with questions or ministrations or conversation (during transition, she didn’t want anyone to touch her). When she was pushing, he was so excited by the tiny glimpses of head we were seeing with each push; he couldn’t wait to meet his baby. He kept encouraging her to keep pushing, she could do it, soon she’d have their baby etc. etc. (I barely had to say a word of encouragement, he was doing such a good job of it all on his own). We pulled the mirror out after the first hour of pushing, and this really made a difference for her. Once she could see her progress in the mirror each push was better and better. The baby crowned in right occiput anterior, and she was able to breathe the baby out in between the contractions in such a way that she didn’t even tear her perineum (she did have a small laceration inside the vagina which required 5 stitches, but the actual perineum itself was intact). When the head restituted, the shoulders came out almost transverse rather than vertically. It was almost as if the baby were spinning inside her very roomy pelvis. The little girl (7 lbs, 2 oz.) started crying almost right away, and her beautiful family all burst into tears (especially the young father), which then made me tear up as well (seeing a family cry always gets to me, every time). The father cut the cord. Afterwards, the baby latched onto the breast like a pro and had a very tasty meal of colustrum while I did the small repair. There was no other midwife in the room with me (my preceptor was out at the nurse’s station, within shouting range, but minding her own business). The saying goes that somewhere around 100 babies, you start to get a clue as a new midwife. I guess that means that I have roughly half a clue, right now, but today, for the first time, I felt like…yes, I really am I midwife.

Rachel commented, in response to my Worry-wart = New Midwife post: “I was interested to see in your description how “medical” the treatment of the L&D patients seems to be, despite having a midwife on hand. Any thoughts on that?”

Of course I have thoughts on that!

First of all, this is hospital midwifery and hospital birth. Unfortunatley, you almost have to think of it as a different species of midwifery all together. Because this is occuring inside a hospital, and there are hospital regulations to follow, there are protocols in place which limit the amount of freedom a midwife has to manage her clients in a more traditional “midwifery” manner, and there is a constant push-and-pull of politics and power at play. Who ultimately gets to make the calls? Is it the women themselves, who are educated and empowered enough to demand the kind of birth experience they want? Is it the midwives, fighting and advocating for these women? Is it the doctors, whom the midwives collaborate with? Is it the nurses, who often choose to ignore the breastfeeding-friendly initiative that’s been established in our hospital, and try to bring the baby to the nursery as quickly as possible after the birth in order to limit the amount of work they have to do right after the birth?

Ultimately, it’s a combination of all of those things which impact the overall birth experience. This is a midwifery service located in a very busy urban hospital in a very poor, underserved section of Brooklyn. Our clients are women from all over the world. Many of them are recent, first-generation immigrants, and presumably many of them are here illegally (we never ask). Many of them don’t speak English—they speak Spanish, Urdu, Polish, Hindi, Arabic, French, French Creole and Patois, predominantly. On the whole, many of these pregancies are unplanned. Home situations vary incredibly. Sometimes the father of the baby is supportive, sometimes they’re married, certainly sometimes it’s a planned and wanted pregnancy, but sometimes the woman and her partner are no longer on speaking terms, sometimes there’s a court order against him, sometimes the aunts and mothers and grandmothers of these women will be raising the baby while the woman goes back to finish high school. Planning for the pregnancy and birth is often done under very difficult circumstances. By and large, these women are not showing up to labor and delivery with doulas and birth balls and birth plans, having read all the latest childbirth books and having bought the latest, most ergonomic birth sling. They’re not online, with internet access, reading blogs like ours or doing research about their birth choices. But most importantly, these women are not choosing midwifery care. They’re coming to our hospital clinic because they can get prenatal care for free with us if they don’t have health insurance and they qualify for medicaid and WIC and PCAP. They’re being taken care of by midwives because their pregnancies are predominantly low-risk and healthy, and because the hospital finds midwifery care to be cost-effective and economical, but are these women seeking us out, or looking for the midwifery experience? Not really. And are these women really after a natural childbirth experience? Again, for the most part, not really.

Women generally see one midwife for their prenatal care, but unfortunately, labor and delivery is covered in shifts. It’s a 24-hour service, so there are always two midwives on L&D at any given time of the day or night, but it may not necessarily be the midwife who took care of you during your prenatal care. Which means that when you come to the hospital to give birth, the midwife you know and are familiar with may be there to deliver your baby, but there’s also a good chance that she won’t be. It’s not ideal, by a long shot, but this is the difference between private practice midwifery, which is often a luxury item reserved for those who can afford it, and hospital midwifery, which serves underserved populations with excellent care, but isn’t set up in such a way that the midwives are on-call for their clients.

So, in a hospital setting, where does the midwifery care come in? We don’t have a birthing center, and there really isn’t a birthing center vibe to the place. However, I think the midwifery aspect comes into play in many areas which aren’t immediately obvious because they’re subtle, but I do think it makes a big difference overall. For one thing, the number of women getting epidurals on this floor seems to be much less to me than in other hospitals where I’ve worked as a nurse (and these were all private hospitals predominantly served by private doctors). I chalk the decreased epidural rate up to the increased labor support the women get from the midwives and the nurses. The c-section rate is also much lower in our hospital than it is in many other hospitals in the city (22% last year, v. 30-35% in other hospitals in NYC, and certainly much lower than the national average), and our VBAC rate is much higher than in many other hospitals in the city, as well as higher than the national average (I think this comes from the fact that there is one dedicated VBAC counselor who counsels all the women, and the midwives really work hard to find the op report and talk to women about the benefits/risks of VBAC). Women are allowed to eat clear liquids (juice/jello etc.) during labor, which is a big improvement over many other hospitals where women STILL aren’t allowed to eat anything (and which is still occurring on a regular basis at other hospitals). Women can get out of bed if they’re not on pitocin (again, something which doesn’t occur that often in other hospitals). We push in side-lying or sitting positions, we push with squat bars, we let women push on the toilet or standing (hanging) in a suspended squat.

More than any of this is, though, is the midwifery philosophy which is held by the midwives, and which is always at work in the hospital. I’ve been working here for only about 4 weeks, but a lot of that time has been spent advocating for natural childbirth and breastfeeding and trying to find a way to limit the number of interventions performed in labor and delivery. As the midwife, it’s a constant struggle. Sometimes it means jumping through hoops, or presenting patients to the doctors in a such a way which highlights the positive (she’s making change, just slowly…but no, I don’t think she needs pitocin or a cesarean or etc. etc.) and downplaying the negatives. It doesn’t mean changing the facts, it just means fighting and doing everything you can to let a normal birth unfold, even in a hospital. It’s a crazy balancing act, balancing so many different needs and agendas and pressures and desires. I think this philosophy can be seen in the amount of patience which the midwives display, the effort put into offering a humane, hands-on touch, and the deeply held belief that BIRTH IS NORMAL, that women CAN do it, that all women deserve respect and informed choice, that they deserve explanations, that no one is going to just walk in and rupture their membranes without talking to them about it first and making sure it’s okay. To me, the midwifery philosophy, at its very core, means LISTEN to WOMEN, DON’T JUDGE, and return the power of labor and birth back to the WOMAN, where it belongs. We don’t deliver babies, we catch babies; it’s the woman who does all the hard work. It’s the woman who delivers her baby. It’s her body, it’s her baby, and it’s her birth. Women in this hospital are powerless in so many ways, and are often so used to giving up there power. They don’t always ask questions because they don’t realize that they have a right to ask questions—that they can ask questions. The midwifery philosophy at work in a hospital helps to correct this imbalance and inequality, even if only a little bit. So much of midwifery care is education, and education is power.

I’ve recently had a birth which really illustrate these points, and which I’ll write about below, but in any case, I do think the difference is palpable. Yes, it’s hospital birth. Yes, there are lots of monitors and beeping machines, there are hospital protocols which must be followed, women get epidurals (but only if they want them), we use pitocin, there aren’t tubs, and unfortunately no one has time to rub lavendar oil into anyone’s back (simply because this is an incredibly BUSY hospital, and you rarely have time to pee, let alone massage someone during labor), but I think we still provide excellent midwifery care to our clients. Even if it wasn’t necessarily the kind of care they were looking for in the first place, I think that many women find that they really enjoy midwifery care, because we as midwives are trying so hard to give them choices, to help them take control of their bodies and their births, to be able to say no to treatments or procedures they don’t want, and of course, treating them with dignity and respect (again, things which aren’t always in large supply in hospital settings).

Case in point: last week I was taking care of a woman who was laboring with a baby that was Occiput Posterior, meaning that the baby was face up instead of face down, and that therefore the back of the baby’s head (the hardest part of the baby) was up against the woman’s back. OP happens quite frequently during birth, and can make labor a lot longer and more difficult, because it’s not the optimal fetal position for a quick and easy birth. And indeed, this woman was making progress, just SLOW progress. She was 6 cm dilated at 8:00 am when we first came on our shift, then she was 8 cm at 10:30 am (when I broke her water because she was asking for something to speed the process up). She was 9 cm at noon, had progressed to anterior lip at 2:00 pm and was finally fully dilated at 4:00 pm. I was getting really nervous because she was gong so slowly and I was conscious of the hospital pressure which always exists, and which goes something like this: as soon as you’re admitted to the hospital, you better be moving towards birth, and moving at a pretty regular, pretty rapid pace. It was my preceptor that day (a big, loud-mouthed woman who’s been a midwife for 10+ years, possesses loads of confidence-born-of-experience—which I don’t yet possess—and is not afraid to tell the truth, whatever that may be) who was the calm rock of this birth. She’s the one who told me to quit checking our patient, to just sit tight and watch her labor unfold and trust that everything is going the way it should. So that’s what we did.

Because our patient didn’t have an epidural and she didn’t have pitocin going (she just had two fabulous midwives, sitting in her room with her because it was a quiet day), we got her out of the bed and let her sit on the toilet for awhile, let her walk a little bit, but eventually she wanted to get back into the bed, so we helped her back into bed and then helped her roll side to side every 20 minutes or so. Position change is a key to managing OP birth, as I’ve been learning; just keep changing position, and eventually the baby will slowly rotate and work its way into an anterior position (that’s the hope, anyway). Luckily, the tracing was beautiful—we couldn’t have asked for a nicer tracing, with these huge, reassuring accelerations into the 170s with almost every contraction—so we weren’t under a time crunch to get the baby out quickly. Everything was going smoothly, just slowly.

Then, once she’d been pushing for about an hour, one of the doctors stormed in (having just finished a c-section) and threw a little hissy fit, right in front of the patient: why is this woman STILL pregnant?!? Why haven’t you started pit? What are you guys doing in here? Start pit! This is ridiculous. Etc. etc. Nevermind the fact that he hadn’t been paying attention to her all day; she was a midwifery patient, and we had been managing her, but now that it was 5:00 pm and he was signing off to the oncoming doctor he suddenly wanted her to have been delivered ages ago (I guess it looks bad to the oncoming doctor that he’s had a patient all day who still hasn’t delivered yet? Again, this is part of the hospital pressure mentality which says “as soon as you’re admitted to the hospital, you better be moving towards birth, and moving at a pretty regular, pretty rapid pace”). This doctor kept saying: she was 6 cm at 8:00 am, what are you guys DOING in here?? She should have had her baby already!! etc. etc.

And to be honest, I was absolutely, 100% cowed and terrified. As a new midwife, in my near-constant state of terror, I have very little confidence in myself or my management skills, and unfortunately this translates to a whole lot of fear right now; fear of birth, fear of doing something wrong, fear of making a really big mistake etc. etc. If it had been me alone in that room, I probably would have burst into tears. I had already been wondering to myself if we should have started pitocin. But no, thankfully my preceptor was in the room with me, and she very calmly, tranquilly and firmly told the doctor to chill his pants. She basically said: we’ll start pit if you absolutely insist (he is the doctor, after all), but she’s having an OP baby, she’s making progress, and things are fine and NORMAL in here, so please leave and let us do our thing. And what do you know…he left! And then we started pit (and actually, for what it’s worth, the incoming doctor got into an argument with the outgoing doctor at the board, stating that our patient probably didn’t really need the pitocin. If her contractions were enough to get her to fully dilated, albeit slowly, then they were probably enough to get the baby delivered.) But anyway, we started pit, and she pushed and pushed and pushed. And here, I think if she’d had an epidural, she wouldn’t have been able to push that baby out, but thank goodness she didn’t have an epidural so she could really feel the urge to push with each contraction, and eventually the baby did a long-arc rotation and was born from right occiput anterior at 5:39 pm, screaming his head off, and voila!….a totally normal labor and birth.

Would that birth have been different if she hadn’t had midwives taking care of her? Yes, I think so. Maybe she would have had an epidural, and been unable to push her baby out. Maybe a different provider would not have accepted her slow progress, and started pitocin on her a lot sooner. Maybe someone else would have considered her lack of progress as “failure to progress” and she would have been taken to the back for a cesarean. Maybe if no one had gotten her out of bed, or sat with her in the bathroom while she pushed on the toilet (something the midwives have to do, because the nurses won’t take responsibility for the patient if she’s off the monitor, so unless the midwife is in the bathroom with her or walking with her, they don’t let her out of bed), maybe if she hadn’t been walking and changing position so much, maybe that baby wouldn’t have rotated. Who knows. The point I’m trying to make is that midwifery care, admittedly in a somewhat altered and modified form, is alive and well in a hospital setting. Unfortunately, there are just more rules to conform to, more egos and personalities to manage, more pressure and time-crunch, and there isn’t that lovely, private-practice one-on-one kind of care which is one of the hallmarks of midwifery care in other settings. Is there still a lot of things which can be changed? Yes, of course. Is there still a lot of things which are far less than ideal in our set-up? Undoubtedly. But I think the midwives are giving excellent care to our patients, in the best way we can, and I think it really does make a difference.

Someone asked me once how I can stand to be around birth all the time, with all its sights and smells and liquids and mess. I told this person that honestly, I very rarely notice it, and it doesn’t bother me, obviously, or else how could I continue to do this day in and day out? In fact, many of the sights and sounds and smells of labor are very encouraging, and when you see them happen, you know that things are going well. The unique, clean, slightly chlorinated smell of clear amniotic fluid, for example, when a woman’s water breaks (at least, it’s always smelled a little chlorinated to me, or maybe that’s just because amniotic fluid is a base, as is chlorine, and I’ve come to associate chlorine with a basic smell)…and how reassuring it is to smell that smell as opposed to the smell of meconium, or foul amniotic fluid that smells of infection. Or when a woman is pushing, how reassuring it is to see her push out a little bit of stool with every push—when you see that, you know that a woman is pushing effectively, and that before long, you’ll be seeing the baby’s head. When you’re watching a baby crowning, the last thing on your mind is the stool. Birth is messy, sure, but it’s so beautiful that you hardly notice the mess, if you even notice it at all.

Even so, some births are definitely messier than others, and I think I just had one of my all time messiest births last Friday. The woman was a multip giving birth to her second baby. She came to triage in active labor, already six centimeters, and things were moving right along for her. We got her into her room, and she spent another hour walking around while we monitored her baby intermittantly. After awhile, she sat down on the birth stool and began to push a little bit, but because she had had a partial third degree laceration with her last pregnancy, we moved her off of the stool and on to the bed, where the delivery could be more controlled and her perineum better protected this time around. She was fully dilated at 7:00 pm, and her bulging bag of waters spontaneously burst at 7:05 pm, and didn’t just burst, but BURST, with water spraying everywhere. We cleaned up as much of it as we could, but there was a lot of it, and more of it continued to flow out with every push. The baby moved down quickly after that and was crowning in no time at all, with the usual amount of stool involved, and we let the head crown slowly so that the perineum could stretch.  The baby was born at 7:20 pm, a gorgeous, squalling 8 lb. girl, which we put on the mother’s abdomen while we went about the rest of the delivery, collecting cord blood after the cord had stopped pulsing, then delivering the placenta, and finally doing the repair (she only had a 2nd degree this time around, which is not great, but at least an improvement over the 3rd degree she’d had last time, and the head had been well controlled and the laceration had occurred in the same line as the original tear). While all of this was going on, the baby decided to demonstrate to all of us that all of her organs were working and all of her orifices were patent, and proceeded to pee all over the mother and then pass a healthy meconium as well. By the time we were done with the repair, the mother and her sodden hospital gown were covered in every possible human body fluid: amniotic fluid, blood, sweat, urine and meconium, and it wasn’t just on the mother, but all over the bed as well….even dripping off the bed and down into the cracks. It was a very impressive mess.

Thankfully, the mother was too overjoyed and caught up with her baby to even notice, and we were quickly able to clean up her perineum, take off her gown, give her a clean one, swab her down, change the chux, and get her and her husband comfortably settled in with their new baby. Even so, she definitely still needed a thorough shower, the baby needed a bath, and my own scrubs needed to be changed as well. No one ever said birth was clean, but have you ever seen a more beautiful mess?

So, my first week of clinicals ended last week, and I am only just now having an opportunity to sit down and write about it. Let me tell you a bit about my schedule: clinicals take up roughly 42 hours a week—2 labor and delivery shifts and 2 clinic shifts—plus one day a week in class, and every other spare moment devoted to either sleeping, eating or studying (well, and blogging…and watching the occassional episode of 24). Labor and delivery shifts start at 7:30 am for postpartum rounds and don’t finish until 9:00 pm. To get to the hospital on time, I need to leave my house around 6:30 am to account for the vagaries of the subway, which means waking up around 5:45 am (did I mention that this hospital has an absolute THOU SHALT NOT BE LATE policy? If I’m late once, we talk about it. If I’m late twice, I’m sent home. If I’m late three times, I need to find a new clinical site). It’s dark when I leave for the hospital, and dark when I come home. Not a very bright prospect for a certain student who really loves her sunlight. I thought I was going to be doing clinicals, but in fact, I think I’m in midwifery boot camp. I must have missed a memo somewhere along the way.

However, clinicals are going well. Much better than I had anticipated—in fact, most of the feedback has been very positive so far, and the preceptors I’ve encountered so far have been a lot of fun to work with. My second shift on labor and delivery involved working with one woman for most of the day. She was a multipara—first baby was 3500 gms, second baby was 4000 gms, and this one was feeling very large as well (we estimated 4000 gms), but she wasn’t diabetic, and she had a large, roomy pelvis, so we weren’t sweating (although we were watching closely, and we had a stool in the room just in case suprapubic pressure was needed in a hurry). She spent the first half of her labor out of bed and walking around (how about that! A hospital that actually has intermittent monitoring protocols that 1) work and 2) get utilized appropriately), but she wasn’t progressing quickly (about 1 cm every 2 hours), and certainly not as quickly as you would expect a multip to progress. We began to worry that if things didn’t continue to progress at a steady pace, the residents on the floor would begin to poke their heads into the room and want to start pitocin…and yes, I know! Progressing one centimeter in 2 hours is just fine, really, and not a problem if you’re at home or in a birthing center…but when you’re on labor and delivery, unfortunately there is a clock that is constantly ticking, and as a midwife on a hospital floor you have to take that into account. So we decided to rupture her membranes to see if that would help get things going. Not a benign measure, by any means, but preferable to pitocin. And sure enough, rupturing her membranes did the trick, and before we knew it, her labor was much more intense, and she was asking for an epidural, which she got.

Things slowed down a little bit after that, but she continued to make steady progress, and by 4:30 pm she was ready to push (we’d been laboring with her for the entire shift, since 8:30 am). We turned the epidural down so that she could better feel the contractions and the urge to push, and began the slow work of pushing that big baby down. Again, it took longer than we had anticipated, and she wasn’t the strongest pusher in the world, but finally, the baby began to crown. And crown. And crown. And we did, indeed, begin to sweat.

The woman had a very short perineum, and there was a little bit of scar tissue from what looked like a prior episiotomy, and her skin integrity was not that great. I gave perineal support as the head was coming out and we got the head over the perineum more or less intact. Once the head was out, my preceptor continued to apply perineal support while I worked on the shoulders. The head wasn’t rotating quickly…it definitley needed some gentle nudging to help it turn. We were concerned about a dystocia, but when I reached up I was able to feel the top of the anterior shoulder, so we knew for certain it wasn’t stuck. Nevertheless, this definitely wasn’t the type of baby that just slips out once the head is born. In fact, instead of holding the baby with both my hands gently supporting the head and neck, I actually had my hands on the shoulders, with one finger hooked under each armpit, and was gently tugging the baby out, bit by bit. I think I finally understand what is meant by “tight sholders” now. It’s not that they were stuck…but it wasn’t an easy fit.

When the baby finally came out, he looked HUGE! As it turns out, he weighed 4400 gms (not quite macrosomic)…but even so, a pretty hefty baby. Definitely took some muscle to lift him up onto his mother’s abdomen, where he proceeded to cry after about a minute of stimulation. Very adoreable baby; he looked like a 2 month old. Welcome to the world, fat and happy baby. There was terminal meconium, and when we had a chance to look at the perineum, there was a pretty nasty third degree laceration there, which baffled me since I was pretty sure the baby’s head had crowned without ripping. My preceptor told me that, given her short perineum, poor skin integrity, prior episiotomy, and just the sheer size of the kid, there was not much else we could have done to prevent it. Even so, I wonder if there was anything I could have done during the delivery of the posterior shoulder that could have prevented such a terrible tear.

In any case, the doctor came in to repair the sphincter, and we finished up the rest of the repair after that, and thus ended my 26th delivery. Tight shoulders. The largest baby I have caught to date.

Look what happens when you do. This is a birth that could have gone so differently if the midwife involved had acted out of fear instead of trust.

I’m delighted to present another edition to the growing library of beautiful birth stories on this site, kindly submitted by RR. Thank you so much for sharing your story with us!

The birth of our son was very eagerly anticipated. Fourteen months before his due date, I had given birth to our first child, a girl, who was stillborn at 24 weeks gestation. I was very medicated during that birth, and didn’’t remember much of it. I was looking forward to not only finally having a healthy child, but to remembering the experience. My birth plan consisted of only two items: 1. Deliver a healthy baby and 2. I would prefer to be conscious and not have any narcotics.

I had been diagnosed with gestational diabetes at about 26 weeks, which was a shocker, considering that I was very fit, trim, and healthy throughout my pregnancy. I was at the gym lifting weights when I was 36 weeks along! The GD was a blessing in disguise, though –I got to have a lot of extra monitoring of my pregnancy, especially in the last six weeks or so. It gave me such peace of mind to go in for my weekly NST’s, and listen to the baby’’s heart thumping away. I had a sizing ultrasound and biophysical profile at 36 weeks, which was incredibly reassuring as well. With my history and the GD, my OB gave me the option of being induced after 38 weeks, or waiting to go into labor on my own up to 40 weeks. I chose the earlier option, and was scheduled for induction at 38 weeks, 4 days.

I went in to the hospital on a Wednesday for cervical ripening. I was about 2-3 cm and having painless contractions when they first hooked me up to the monitors. My NST a week before had shown contractions, but I really didn’’t feel them at all, so it was fascinating to watch the monitor, and figure out what was going on with my body, all the while hearing the baby’’s heart thumping away. After the baseline monitoring was done, I got a dose of cytotec in my cervix. By morning, I was a little more than 3cm, but much more effaced. I got another dose of cytotec, and was still having pretty painless contractions - nothing more than moderate menstrual cramps. The nurses kept asking me if I felt any contractions - apparently, they were pretty strong on the monitor, but I was barely feeling anything at all. At noon, the OB came to check me and I was 4 cm, so he went ahead and ruptured my membranes. The nurse asked if I wanted an epidural so that she could start IV fluids before they started pitocin and page the anesthesiologist. I almost hesitated since my “labor” had been entirely painless to that point. Well, I didn’t need any pitocin. Within a minute of my membranes being ruptured, I was having INTENSE one on top of the other contractions with no breaks in between. It seemed like suddenly the lights were all too bright, and everything was too loud, and just could NOT stand anyone asking me any more questions. I did my best to just concentrate on breathing during the contractions.

The anesthesiologist arrived at 1pm, and I was checked again - I had gone from 4cm to 8cm in just under an hour! At that point, I remember some discussion about whether or not there was even time for an epidural. There was some commotion in the room that I couldn’t figure out, –I was too busy just breathing. The anesthesiologist was able to get the epidural started, however it was working only on my left side - the right side was feeling everything, and I got incredibly nauseated and was vomiting. As painful as the contractions were, the vomiting was the worst part for me. After almost an hour of fiddling with the epi and the dosage, the anesthesiologist took it out and did another one - heaven!! At that point, I looked over to the baby warmer and noticed that everything had been set up for the baby’s arrival, explaining the commotion earlier. Thankfully, the epi slowed my labor a little bit, because the baby had been having some accels and decels in his heart rate that seemed to concern everyone but me. I started pushing at 4:10 pm, when I had just a small lip of cervix left. My epidural was just right: I couldn’t feel intense pain, but I knew when I was having contractions, and had no trouble pushing. The nurse coached me through a few different positions to help move the baby down better. By 4:45, my cervix was completely gone. Near the end of pushing, the baby’s heart rate was accelerating again, so the OB got ready to use the vacuum on him. However, I was able to push him out all on my own, and he was born at 5:56 pm. There were many tears of joy. My husband and I were beyond relieved to have our son safely with us at last. His apgars were 8/8, and he weighed 8 pounds, 5 ounces. Fortunately, I had only one very small tear that required a stitch or two. All in all, this labor was really a breeze, – much easier than I was expecting it to be.

My husband was such a trooper! I had prepared him for a long a boring labor, and we definitely weren’’t expecting it to happen so quickly. We’’d left all our music in the car, thinking that he’d go out and get it during one of the boring parts, but there were no boring parts! Once my labor got going, I really didn’t care what music was or wasn’’t playing. My husband and I were just focused on getting our baby boy into the world. It was so amazing to finally meet the little person we’’d been imagining for so long.

And then people send me beautiful, delicious birth stories like the following, which was written by my friend Miriam, and I am so grateful that births like this exist! Congratulations on your lovely birth, which would have most likely become an emergency c-section if it had occurred in the hospital (since very few doctors know how to deliver breech presentations, and it’s no longer even taught in med school). Three cheers for homebirth! Enjoy:

Nadia Tell was born on Friday, May 19. She was 37 weeks and 2 days gestation, and is healthy and wonderful and loved.

Thursday, May 18, was a gorgeous perfect May day. I walked down to the Chocolate Gecko and spent a good two hours chatting with Lissa, the owner, while she dipped an order of chocolate-covered fruit (and fed me the ones that got marred by being dropped on the counter). She was talking about other young families in the neighborhood and wanting to put us in touch, and generally thrilled to hear all about our plans.

On the way back I stopped in the dollar store and CVS for some final birthing pool-related supplies—sponges, a hand mirror, an inflatable ring. It felt, like much of the rest of our prep, like I was ticking off the ends of a list by a deadline so we could be well-prepared well ahead of time. I wrote a piece for Metroland’s summer guide that wasn’t due until June 1, and sent it in, cleaned the microwave, and sat on the porch enjoying the weather with Mary, knowing from her that the weather report was predicting big storms coming in and rain for days. It felt like it was likely to be one of many similar days to come. I had lots of things to do, but nothing felt urgent, and I was enjoying the calm.

I made dinner since Robin and Rebecca had somewhere to be early evening. We put off our usual Thursday grocery run until Friday. Over dinner we discussed the far-fetched proposition of buying the Chocolate Gecko (Lissa’s selling and was pushing it). It was a fun and fanciful conversation. I was writing something about it in my journal before bed, and sat down on a stool in my bedroom to note down a few last thoughts.

As I leaned forward I felt a tiny movement down low near my cervix, and sudden there was a flood of warm liquid all over the floor. It was hard to believe and yet unmistakable. I stood up, still gushing, and called “Hey guys?” A face popped out of the bathroom and another from their bedroom. “My water just broke.” (Read on …)