As an example, very recently for me I had a baby who needed full-on resuscitation after the delivery, and I was absolutely shocked and baffled by it.  It was a full term baby, we’d been continuously monitoring the heart the entire time she was pushing and everything was looking good (up to the last few minutes when the baby slipped under the pubic bone and it become incredibly hard to pick up the fetal heart rate…and granted, a few minutes can make a big difference if the baby’s heart rate was decelerated during those minutes, but overall the tracing had been very reassuring).  She wasn’t even pushing for that long, you would expect everything to turn out well, or at least expect the baby to pick up very quickly after some drying and stimulating….and yet, shockingly, the baby came out blue and needed not just positive pressure ventilation with a bag and mask, but chest compressions as well (which you only have to do if the fetal heart is less than 60 and isn’t picking up, and which most babies rarely ever, EVER need; prior to this delivery, I had seen chest compressions done only two other times in my 8 year career as a Labor & Delivery nurse and now midwife).  The Apgars for this baby were 1 at one minute of life (which means the baby had a pulse, and that was it), 4 at five minutes, and 7 at 10 minutes (which is certainly a decent enough score, if not absolutely perfect).   It was a full three minutes before the Peds team arrived on the scene; I was ventilating the baby while the nurse did chest compressions.  And thankfully, in the end everything turned out well; we resuscitated the baby, the baby recovered nicely and went home two days later perfectly normal, but nevertheless, it was absolutely terrifying.  Afterwards, as we were recovering and debriefing and waiting for our own heart rates to return to normal, the only issue we could see was that the mother had had chorioamnionitis (an infection of the amniotic cavity), and one of the attendings pointed out that he has sometimes seen chorio do that to a baby before.  It wasn’t something I had ever seen before, and chorio had never been something I had routinely called pediatricians to a delivery for in the past, but now it gave me pause.  And the next time I had a woman pushing with chorio (only about a week later), you can be damn sure I called Peds to the delivery, well before the baby actually came out.  With that birth, everything was fine, the baby was pink and vigorous with Apgars of 9/9, and the pediatricians were  wondering why I had called them for something as routine as chorio.  I called because personal experience had made me cautious, and has temporarily changed the way I practice.  The next time I am pushing with a woman who has chorio, I may decide to call Peds again, or maybe I will decide to wait and see.  I suspect that gradually over time it will become less scary again, and become more integrated into my overall practice, but I will always and forever add chorio to my mental check-list of reasons why we may need Peds at a delivery, and will probably make the call based on several factors, like 1) how long has she had chorio, 2) how long has she been pushing, 3) how has the tracing been overall, 4) how high has her fever been etc. etc.   And a full-on resuscitation is now always going to be one of the possibilities I consider with a woman who has chorio (although technically it’s something we’re supposed to always consider with every delivery, and it can and does happen out of the blue sometimes for no apparent reason at all); always, always, from here on out.

But personal experience isn’t always negative, or built upon bad outcomes and our responses to them.  I was writing to a friend the other day about how my practice as a midwife has changed now that I’ve given birth myself, and I also find this very interesting to stop and reflect on a bit.  The most obvious change I can think of is how I handle women in early labor/ prodromal labor. This comes from my own experience of an endless early labor which lasted for nearly 2 days.  I think in the past I was a bit more terse with women coming in to the hospital in early labor, only to be sent home again because they were only 1 or 2 centimeters dilated.  They weren’t in active labor yet, and that was that.  Which isn’t to say I wasn’t sympathetic and sweet about it, but I didn’t spend nearly as much time talking with and encouraging these women as I do now.  Now my heart goes out to them so completely because I can so well remember what that’s like.  It’s not like my contractions were irregular and mild—they were strong and regular and painful to me, at the time.  Albeit they were nothing compared to the contractions that were yet to come, but since it was my first time laboring, I had no idea of what was yet to come, and in the beginning, the early labor contractions were PAINFUL.  I spend so much more time with these women than I ever did before in triage, going through what’s normal and what’s not, reassuring them, talking about what (limited, because nothing really helps that much) comfort techniques they have at their disposal.  I’m even more patient with them, and even more understanding.  In this regard, I think empathy is quite valuable–which isn’t to say that you can’t be a good provider if you haven’t gone through it yourself—but I do think it adds another layer to my care which wasn’t there before.

Strangely enough, though, if I’ve become much more patient with women in early labor, I’ve become much more practical and maybe even a bit tougher when it comes to second stage.  In the past, having never pushed a baby out before, and having no idea what that actually felt like, I was incredibly sympathetic to the agonies of pushing.  I would allow women to say things like “I can’t” again and again during pushing while I calmly and unflaggingly told them again and again and again that they could.  For me, this was the epitome of midwifery care—this spoke to the very root of my calling, helping women to find their own strength in the moments when they were convinced that they had no strength left, helping women to climb the mountain that they thought they couldn’t climb.  However, having now pushed out a baby myself, I feel like I cut to the chase much more quickly during the pushing phase than I ever used to in the past.  I can remember just how excruciating the pushing was, and I know all too well that there’s no cure for the pain except to GET THE KID OUT, and I no longer hesitate to use tough love to help women buck up and PUSH, or hunker down and PUSH, or get to work and PUSH, if it seems like that is appropriate and will be effective.  It’s become another tool in my arsenal.

Granted, there is a time and place for everything, and there are certainly some women who will always need a softer touch, and as a midwife you are always acting like a chameleon; in a way, that’s the hallmark of what good midwifery care is.  Because women are so different and because labors are so different, what works in one situation doesn’t work in another situation. There is no cross-the-board answer.  I can get away with saying something with one woman which I would never dream of uttering with another woman,  based on my personal relationship with that woman, and on who she is and on what is needed minute by minute.  And often the situation itself dictates the tone; sometimes the energy in the room is very high, and you can joke around and be loud and loving and teasing, other times the mood is very subdued and quiet and she is working hard and inwardly focused, and what is needed is a soft touch or a single word.  You have to know how to surf the different energies at different times.  But now, thanks to my own personal experience of birth, I try to get women through second stage as efficiently as possible, to try to keep the pain from being drawn out longer than it needs to be.  Because man oh man is it painful!

Experience can be both a blessing and a curse, but it’s all of these little moments strung together which makes you a better provider.  This is the reason you seek out providers who’ve been doing this for awhile, who’ve seen the good, the bad and the messy, and have learned how to integrate it into their larger view.  For all my midwife sisters out there, how has your personal experience changed you?

I caught three babies on Friday.  The first woman was already 6 cm dilated when I got onto the floor.  She had just arrived, and had already been brought into a birthing room, knowing that it was her third baby and that things were moving fast.  She was groaning and sweating when I entered the room.  She was by herself; her husband was at work and her sister was at home watching her other two children.  My heart instantly buckled at the thought of being alone during birth.  There is NO WAY I could have made it through my own birth alone.  I sat on the edge of her bed and didn’t want to leave her side (and thankfully, things were progressing fast enough that there was no time for me to be pulled in any other directions).  The sights and sounds of labor instantly took me back to my own very recent birth.  It was almost visceral.  I could almost feel it in my body like a phantom pain.  She looked at me with the slightly panicky eyes of transition, and I could instantly remember my own transition, vomiting over the edge of the birth tub, sweating and shivering at the same time.  For a moment I wasn’t sure how to even help her; I felt like any comforting words are so inadequate compared to that pain.  But she wanted me to do something, so we talked briefly about what her options were.  Pain medicine, or just getting the labor over as quickly as possible.  She just wanted to be done with it, so I broke her water.  We barely had enough time to get the birth kit open before the baby’s head was visible on her perineum.  Three good pushes and the baby was out at 8:38 am, a 7 lb healthy little girl with a strong cry and a head full of hair.  The mother hadn’t known the sex of the baby in advance, and she wanted the father to help her pick out the name.  She cradled her baby but unfortunately couldn’t breastfeed her immediately because we didn’t know her HIV status (somehow this test had been missed during her prenatal care!) and per hospital policy she wasn’t allowed to breastfeed until the results came back.  I left the two of them bonding and stepped back out onto the craziness of the floor.

The second delivery happened at 3:48 pm.  This mother was a thirteen year old girl who looked as if she were 21.  Her half-sister and mother were in the room with her, and had been with her for nearly 24 hours.  She had come in the day before with sky-rocketing blood pressures, and was currently being induced for preeclampsia.  She was on magnesium, and had been making very slow progress.  When I first examined her in the morning (shortly after delivering the first baby), she felt to be about 5 cm dilated, which was exactly like her last exam four hours ago.  This wasn’t the kind of situation where we could tolerate a slow and meandering induction; the cure to preeclampsia is birth, and we needed her to deliver sooner rather than later because her blood pressure was a bit scary: 160s over 110s (so high that we actually administered 5 mg of hydralazine at the start of the shift to try to stabilize her somewhat).  The attending suggested that we break her water to try to get her labor going, but I thought pitocin might be a better option.  Yes, a midwife pushing pitocin!  However, with a slow, drawn-out induction, I felt like breaking her water at only 5 cm was an invitation for an infection, and that there were other ways to encourage her progress without taking that route.  In my limited experience to date, I feel like breaking the water in a multiparous woman who’s clearly progressing quickly is a sure-fire way to speed things up, but in an adolescent primip, there was no guarantee that breaking her water would do anything.  I argued my case and the attending agreed.  We began pitocin and left her water intact.  She didn’t want an epidural, but she took some stadol twice to help her cope with the pain, and around 1:00 pm when I reexamined her she was 7-8 cm dilated, and the baby’s head had moved down considerably.  I broke her water at that point, and she began to feel like she needed to push around 2 pm.  I checked her again, and hallelujah, she was anterior lip.  We tried some different position changes to try to encourage the lip to recede (including hands and knees–the beauty of no epidural!), and around 3:00 she felt like she had to go to the bathroom (music to a midwife’s ears) and wasn’t able to stop herself from pushing.  She began to push, and almost immediately you could see the baby’s head.  We pushed for about 40 min, and she truly was a superstar, giving birth to a healthy 7 lb 4 oz baby boy!  I kept forgetting that she was only 13 years old, such was her maturity and resilience.

The third delivery happened at 7:31 pm.  This was a woman whom I had been taking care of all day, but I wasn’t sure I would be the one to deliver her.  Her water had broken the night before, and she was contracting on her own when I first arrived onto the floor in the morning.  I only checked her twice during the day.  Once around 10:00 am (she was 3-4 cm dilated at that point) and again at around 4:00 pm when she decided she wanted an epidural (she was 5-6 cm at that point).  Shortly after the epidural, while I was up to my neck in triage, her nurse called me because she was having an excruciating headache.  I couldn’t figure out what could be causing such sudden and extreme head pain aside from the very recent epidural (and I did call the anesthesiologist to have him come evaluate her, since a spinal headache is a known complication with epidurals).  She had asked her family to darken the room, and when I walked in she had a washcloth over her eyes.  Her blood pressures were also rising, so I asked her nurse to draw some preeclamptic lab-work on her just to make sure it wasn’t that (photosensitivity and headaches are some of the toxic symptoms of preeclampsia).   While we were waiting for the anesthesiologist to show up to assess the headache, she began to feel like she needed to push.  I didn’t want to examine her again (with prolonged rupture of membranes, the fewer exams the better), but it was pretty obvious that something had changed and the labor was going much more quickly all of a sudden.  She felt like she needed to vomit, so we quickly got a bucket under her; her family fed her ice chips and fanned her face.  This was getting on towards the end of the shift, and by that point our triage room was overflowing, with pregnant women pacing the hallways and filling chairs in the waiting room.  I left her to return to triage, only to be called back by her nurse again about 10 minutes later.  When I walked into the room, the nurse was hastily opening up the birth kit, and the head was visible on the perineum (so much for checking her again….clearly she was fully dilated!).  It was one of those deliveries where I barely had enough time to get my gloves on before another healthy little boy joined us earthside, all 9 lbs and 7 ounces of him!

The rest of this woman’s delivery proceeded normally; the placenta came out without any fuss, and I repaired the tiny 1st degree laceration that she had.  Amazingly, her terrible headache also seemed to miraculously disappear as soon as the baby was out, which was a big relief, since spinal headaches are miserable (and preeclampsia isn’t much fun, either; we sent her bloodwork anyway, just to be on the safe side). However, there was a thin but steady trickle of uterine blood which wasn’t stopping, despite the usual postpartum pitocin in the IV bag.  We emptied her bladder with a straight catheter (sadly, when there is an epidural on board, most women have a really hard time urinating on their own), and by compressing her fundus, I was able to extract another 300 cc of clots.  I thought this would do the trick, but the slow trickle of blood would not let up.  This was around 8 pm (shift-change time).  I was exhausted, my own breasts were sore and in desperate need of being pumped (I had only had a chance to pump once, at 10 am, such was the business of my first day back!), and I hadn’t had a bite to eat or drink since noon.  We gave her 1000 mcg of cytotec to try to stem the bleeding, and while her fundus firmed up nicely with this medication, it was still very high in her abdomen (well above her belly-button) which made me suspect that there were still lots of clots inside which needed to be removed before her uterus could contract down like normal and stop trickling.  At this point I called the attending, and thankfully one of the fresh night-shift midwives stepped into the room to help out.   I gave report to the oncoming midwife, who gowned up and put on a pair of sterile gloves, and thankfully took over.  I *hate* to leave a delivery unfinished like this, but it was already 8:30 pm, I felt like my breasts were about to explode, and with my husband away for the weekend, there was no one to relieve our son’s babysitter except for me, so I had to get home asap (as it was, I was an hour late).  When I stepped out of the room, the attending and new midwife were beginning to explore their options in terms of stopping the trickle.  Later that night I received a text from the midwife who had taken over, and in the end, it did indeed turn out to be a bunch of clots which needed extracting.  Apparently, everything had turned out well once those pesky clots were out of the way.

I came home sore, exhausted, exhilarated and desperate to see my little baby boy (who was sound asleep by the time I got home)!  I had never been apart from him for longer than 4 hours since he was born.  Being away from him for a solid 14 hours was a real shock to the system!!!  In a way, I am very grateful that it had been such a busy, crazy day, because it didn’t give me much time to dwell on how much I was missing him, and our babysitter thankfully sent me text pictures and updates throughout the day, which eased the pain of separation somewhat.  I crept downstairs into our bedroom and spent at least 10 minutes staring at him in silence while he slept, just soaking up his sweet, peaceful face.  Then I tip-toed back upstairs to pump.  I nearly fell asleep while pumping.  It’s been awhile since I had had such a hectic day.   Overall, though, it felt really good to be back to work again, and I felt so honored to be attending births once more.  This will definitely take some getting used to, though–a new routine, as both a midwife and a mother.

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I believe that the act of giving birth is in itself empowering, and that birth is capable of transforming a woman even if there wasn’t a lot of forethought or planning put into the where, why and how of it.  When we widen our gaze and look at all the ways that women can be empowered even in situations which don’t, on their surface, look like they are, we see that empowered birth comes in all shapes and sizes, just like women do!  Empowered birth happens whenever a woman decides: this is my experience, my birth, my baby, MINE, and I claim it.

The Empowered Birth Blog Carnival was lovingly hosted by Child of the Nature Isle and Betsy Dewey

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We invite you to sit, relax and take time to read the excellent and empowering posts by the other carnival participants:

Empowered Birthing – Amy at Anktangle shares a simple list of things that support an empowered birth experience.

Little Miss Green’s Home, Water Birth Story – Mrs Green at Little Green Blog shares her (home, water) birth story. Even though it happened 10 years ago, the empowering feelings are the same to this day (and yep, it STILL makes her cry!). This post is also a tribute to her husband who was there mind, body and soul throughout.

Save Birth, Change The World – Toni Harman, mum and film-maker talks about the highs and lows of creating the ONE WORLD BIRTH film project dedicated to helping more women around the world have empowered births.

12 Steps to an Empowered Natural Birth – Terri at Child of the Nature Isle wants to talk to all pregnant women and tell them YES they can have an Empowered Birth! This is her personal 12 step guide.

The Blessingway: a sacred blessing for birth – The Blessingway is a sacred ceremonial circle of women gathered with the intention of blessing and preparing a pregnant woman and her child to give birth. Betsy Dewey describes the beauty and the how-to of a modern Blessingway.

Informed Birth is Empowered Birth – Darcel at The Mahogany Way Birth Cafe tells us why it’s important to take control and be responsible for our own births. She says Informed Birth is Empowered Birth.

An Empowered First Birth – Zoie at TouchstoneZ follows the path she took to her first homebirth and finds she may not have started out as the best candidate for an empowered birth.

And this one to be published on Sept 12th :
Empowered Birth: From the Personal to the Universal – Zoie at TouchstoneZ questions the criteria for what makes an empowered birth and finds she has to let them all go.

My one hope is that they don’t just focus on birth in the developed world (although, granted, we’re desperately in need of a birth revolution here in the developed world), but also tackle some of the ongoing issues in the developing world, too.  I can’t wait to see what comes next out of this! Viva la revolucion!

One of the women from this group was also willing to share her birth story here on Belly Tales, so with her permission I am going to post it. Her name is Katie, and she gave birth to a beautiful son, Sebastian, at home in a birthtub.  This is their birth story, written by Katie:

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I had a lot of nervousness going into my third birth. Mostly I was nervous about the length of labor, tearing, shoulder dystocia and some other things. My second birth was my first home birth, and it was great; however, there were a few complications, all of which were handled marvelously by my midwives. At a blessingway that my friends threw for me, I was asked to tell about my ideal birth, so I did. I was nervous to say things like” it was short,” or “I didn’t tear.” I did, though, and I just hoped it would turn out that way.

Both of my boys were born after their due dates, so I was sure I had 40 weeks before I would have my baby. I worked hard to get all of my writing done so that I could relax for a week before the baby came.

On Monday morning, May 9, when my husband Michael’s alarm clock went off, I told him I’d been having some regular contractions for a bit, and since I’d been having contractions on and off for a couple of weeks now, he reminded me that they were probably just Braxton Hicks warm-up contractions. I agreed. After a while, I got up and went to the bathroom. I noticed, though, that I had lost my mucus plus, so I knew that these contractions were different.

I kept about with my morning plans, though. I went to eat breakfast with a friend, and on the way, I called my midwife to let her know that I thought maybe I was in early labor. After breakfast, I was going to go to the YMCA to walk to the track and help move things along, but since my midwife was in the area, she decided to come over and see how things were progressing. She checked me around 11 a.m. and said that I was almost four centimeters dilated. I was shocked. My contractions were about four minutes apart, and they weren’t even that painful. She told me to try to take a nap that afternoon. She also told me that she had another mom in labor, which made my heart sink. That mom was also about four centimeters dilated as well.

After she left, I decided to take Atticus to lunch on his way to preschool. He enjoyed that, and when I dropped him off, I told his classroom assistant that I would likely have the baby later tonight, as I was four centimeters. She looked at me in complete shock, like, “Why are you driving and walking around right now?” It cracked me up.

When I got home, I did lie down, and I tried to sleep, but my excitement was too overwhelming. I knew I needed to conserve energy at that point, so I just grabbed my laptop and watched some TV shows on Hulu to keep me distracted. I watched the most recent episodes of “The Office,” “30 Rock” and “Parks and Recreation,” in that order. By the time I got to the last TV show, I had to pause the show during a contraction, get on all fours and rock through the contraction. It was becoming more intense. Atticus came home from school, and he watched me labor for a bit. He asked a lot of questions.

I called my midwife and told her she needed to come again. She got there around 5 p.m., and checked me again. I was only at a 4 ½! I was sure I was further along as the contractions at this point felt more intense. I was discouraged and thought that I was in for a repeat of August’s slow labor. Plus, her other mom in labor was at six centimeters, and I felt so nervous that I wouldn’t get to have my midwife at my birth.

My midwife’s assistant arrived around 5:30 or 6, and she and Robyn, my midwife, went outside to discuss what they would do. When they came back, she said that she was going to stay with me and send her assistant to the other mom. She also called my friend and midwife, Mary, to stay with us and be with me when and if Robyn needed to go to the other mom.

During this time, Michael started filling the birth pool, so when that was done I got in it. The water was definitely not hot enough for me, so he started boiling pans on the stove to fill it with hotter water.

During this time, my contractions stayed three to four minutes apart, but I needed a lot of help getting through them. I had to hold someone’s hand through each one. I would either blow my lips out like a horse through the entire contraction, chant things like, “I am strong,” “I am bigger than this” or “it’s ok” over and over again. I tried some of the same visualizations I used for August’s birth, but they didn’t work for this one, so I made new ones. I also told myself that I could do anything for a minute. I stayed in the pool for a couple of hours, just working through the contractions like this and thinking I had a very long way to go.

At one point, my midwife told me that she thought I was a lot further on. So, when Mary arrived around 8:30ish, she wanted to check me again, because she thought the baby would be born very soon. I was shocked to hear that. When Mary arrived, she checked me, and I was dilated to an 8 or 9 with a bulging bag of water. I could not believe it. I was sure I was going to be laboring all night. How in the world could I be that far along? I felt like even though my contractions were very painful, they weren’t even that close together yet.

We decided to break my water, and as soon as that happened, I felt tons of pressure, and knew that it was very close. My midwife helped stretch my cervix through two or three contractions, which, of course, was painful, but I knew it meant the end. That was about 8:45. Atticus and my mom joined the rest of us in the bedroom. I liked that Atticus was there. He just stood next to Michael and watched everything.

I couldn’t believe how quickly I felt the need to push. He was right there, and I could tell. During my next contraction, I started pushing his head out, and it really hurt. I kept saying that it hurt. I said I couldn’t push anymore. So, the midwives said it was ok to just breathe and pant a bit, which I did. It still hurt, but at that point, that felt better than pushing. I still could feel him moving down, though.

It was intense, and at one point, I saw Atticus run away, and that made me sad, but I knew it was probably best at that point. While he was crowing, the midwives remarked on his black hair, so I put my hand down and felt it. I could not believe that that was my baby’s head and that I would meet him soon. That made me want to push harder.

Throughout my pregnancy, I had expressed to my midwife how I didn’t want to tear as much as I did last time. While I was pushing, she was using oils to help me stretch and putting a lot of pressure on my perineum. While it was happening, though, I was sure I was tearing, because it was so intense and painful.

After his head was out, the midwife checked for cord, and then I start pushing the rest out. It felt like it took a while to come out, but now, when I look at the pictures, I see that it was less than a minute. As soon as he was out, I grabbed and just loved on him. I was so relieved it was over, but I was also so happy to be holding him. And I just couldn’t stop staring at his hair! There was so much of it! He also looked so small, as August was almost nine pounds, and this baby looked teeny-tiny compared to that. I kept hugging him, and the other people in the room reminded me to check to see is he was a boy or girl.

I knew he was a boy as soon as I saw him, and my suspicions were confirmed as soon as I looked. I had wanted a girl, admittedly, but when I saw him, I didn’t care one bit that he was a boy, and I thought about how great it would be to have three little boys, and how cute they all would be together.

I got to stay in the tub for a few minutes. I was still crampy, and I tried to push the placenta out, but it wasn’t coming yet, so I decided to get out of the pool. I didn’t want to cut the cord yet, so Michael helped me stand up, and my midwife held the baby close to me so that he could stay attached for a bit longer.

I tried to nurse him to help the placenta detach, but he was so quiet and just not really interested. I gave a few good pushes, though, and it finally came out. After some inspection, my midwife said she didn’t think that I would need stitches. I was in complete and utter shock. I was also thrilled.

My midwife had been in contact with her assistant who was with the other laboring mom, so she had to leave to be with her, which was fine with me. I was just so thrilled that she had been able to be at my birth. After she left, Mary helped me get cleaned up and settled in bed.

The next day we named our boy Sebastian Michael. He weighed 8 lbs, one ounce and was 20 ¼ inches long.

I still can’t believe that everything I wanted for my birth came true: no tearing, no shoulder dystocia/easy passage and relatively short(er) labor. I feel quiet lucky.

It’s funny to be writing this.  I have heard and listened to so many women share their birth stories with me, posted birth stories here on my blog, attended births and helped women write their birth stories, but now I come to a first for me: the writing of my own birth story.  I think there’s something really important about writing your birth story down, for so many reasons.  First, it helps you process something which is almost too big to process, too mysterious and transformational and ephemeral; writing it down helps capture it in a way that can be recalled.  It turns it into a story, something which can be retold and remembered, something which can be shared with others, something which can take on mythic qualities the more you share it.  It can offer guidance or inspiration (if it’s a positive story) or confirm fears and doubts (if it’s a negative story); it becomes part of the framework that women use to understand birth, and I believe that the sharing and retelling of these stories if vital for women, and a very important part of the postpartum healing process.

So, without further adieu…

Labor for me started on Saturday May 14th.  I was 39 weeks and 2 days pregnant, and was very ready to give birth.  I had stopped working at 38 weeks, and had spent the last week finishing up the few small things on my to-do list, but mostly I spent it resting and reading my novel, getting a last pre-birth pedicure, catching up with friends, and waiting, waiting, waiting.  Wondering when it was going to start, when I would go into labor, what labor would be like, how long or short or awful or ecstatic it would be…

I’ve been keeping this news to myself for quite some time here.  I guess I’m finally ready to blog about it (not that anyone is currently reading this anyway, so it’s more or less like writing in my journal), but guess what??  I’m pregnant!  And not just a little bit pregnant, I am actually quite pregnant: 34 weeks today, to be precise, just three weeks away from full term.

We’re planning a homebirth with two lovely homebirth midwives in attendance  who have been caring for me since I was 10 weeks pregnant.  There will be a doula as well (one of my good friends who is also a Labor & Delivery nurse, whom I met while working as an L&D nurse back in 2003), and of course my husband, and my best friend; a small but incredibly supportive birth team.  And a birth tub, which we’re renting (and which we still need to pick up).  The list of things I need to prepare for the birth is still quite long, and a bit overwhelming, even.  At this point, we still don’t even have a name for the child yet (who is a boy, btw; even if I had wanted a surprise, I knew exactly what I was looking at during the sonogram, and could see the tiny little penis quite clearly).  We don’t have a pediatrician picked out, either.  The birth kit is in the mail but not yet arrived. And don’t even get me started on the list of baby stuff which we still need to acquire before the birth, diapers being priority number one. There is a lot to get done in the next few weeks.

From an emotional standpoint, though, I feel like I’ve been taking it all pretty well in stride.  I’ve had (thankfully) a very healthy and straightforward pregnancy so far.  I’ve felt good for the majority of the pregnancy, aside from some nausea and fatigue in the first trimester; all of my blood tests have been normal, the sonogram looked good, everything is healthy and low-risk at this point.  He’s a very active little guy, he squirms and moves nearly constantly, he likes to dance while I’m listening to music, and always kicks his happy appreciation of all of the good food I’ve been eating during the pregnancy.  Current pregnancy complaints amount to a sore back (totally expected, in the third trimester), and having to get up and pee about 3-4 times a night.  I’ve been working my usual schedule, and if all continues to go well, my intention is to work up until 38 weeks, or until I give birth, whichever comes first.

When I was a younger woman, still in midwifery school, I used to worry about my own birth.  I used to worry that I would know too much, that I wouldn’t be able to turn my brain off and surrender myself to the forces of labor when the time came, that I would be the classic example of the woman who’s trying to give birth with her brain rather than her body, and whose brain is getting in the way of the labor.  I worried that something bad would happen; there is a superstition among healthcare workers that pregnant nurses/ midwives/ doctors etc. tend to have a much higher rate of rare and frightening emergencies during their labors and births which somehow necessitate every intervention under the sun, or result in tragic and terrible outcomes.  I have heard this superstition passed around before—that bad things always happen to healthcare workers—and when I was younger I used to worry about it too.  And I have worried in the past that I will somehow by disappointed by my birth experience—that because I have so much knowledge, and such a love of birth, and so much expectation going into it, that inevitably there is no way my own birth could live up to such high standards.  The flip side of this is the fear that I am never going to be cared for as well or as completely as I care for other women; that the care I receive will fall short of my own lofty standards and expectations, and that I will never be given as much as I have given to other women during their births.

Like I said, these are old worries.  I stumbled across them while I was paging through an old journal of mine a few weeks ago, written down in 2005 while I was taking a Birthing From Within mentor training course in order to be able to teach Birthing From Within childbirth classes.  Strangely enough, these worries now seem foreign to me.  At least, they’re not the things I’ve actually been worrying about during my pregnancy.  I feel like the birth will be very difficult—the hardest thing I’ve ever done in my life—but that it’s totally do-able, and that I will absolutely get through it, however hard or long it is.  I’m not really hung up on interventions, or trying to ensure that they don’t occur.  I feel like I’ll have them if I need them, but if all goes smoothly, then hopefully it will be a straightforward, uneventful homebirth. I don’t feel like I’m dead-set on a homebirth no matter what; if there are recurrent decels, or thick meconium, any indication of severe distress, or any other pressing reason, we’ll go to a hospital.  If I need a cesarean in the end, at least I know that I will be one of the women who really, truly does need a cesarean, rather than getting pressured into it by an impatient or uncaring provider.  If I’m having an exhausting 48+ hour labor with excruciating back labor and things are going really slowly, I’m not opposed to an epidural, either, and some rest.  Thankfully my midwife has hospital admitting privileges if we need them, and there is a hospital very close to us for emergencies.  I don’t think we’ll end up in a hospital, but I’m ready to weather whatever my birth throws at me, and I’m trying to cultivate a flexible roll-with-the-punches attitude.  But I think of all the births I have attended (326 now, and counting), each unique in its own way and yet also so similar, and I think of all the women who I have been with who get to a point where they truly believe that they can’t go on, that they can’t do it, that their baby will never come, that they’ll never give birth etc. etc…and then I watch them climb that mountain and get over it and do the impossible thing they didn’t think they were capable of, and give birth—simply, normally, vaginally, uneventfully.  And honestly, it gives me tremendous faith in the process.  I’m sure I too will get to the point where I am convinced I won’t be able to do it…and then I will.  I have faith that I will, and I feel like my faith is what will get me through it (and my smart and attentive care providers will make sure that we’re not taking any unnecessary risks, should we fall off the curve of normal, and I trust them, and their judgement, implicitly).

So no, I haven’t been worrying much about the birth.  I’ve been worrying more about motherhood, about the huge and tremendous responsibility which is about to descend on me.  I’ve been worrying that I won’t be a good mother, or a good enough mother, that the task will be too much for me, that my child will hate or resent me, that I’ll somehow mess my poor child up in terrible, Freudian, unfathomable ways.  And of course I’ve been worrying over the health of my baby.  I pray that he’ll be healthy, and neurologically intact, and strong.  Every pregnant woman does, I’m certain.

But I took the time to write down a gazillion birth affirmations last night, and I’ve been saying them to myself regularly today.  Simple things, but I also believe in the power of positive thought:

I am a strong and powerful woman. I believe in myself. I trust my body.  My baby is strong and healthy. My cervix knows what to do.  I have an open heart.  I am surrounded by loving, nurturing support.  I trust my inner wisdom.  Birth will come easily to me. I have everything I need. I welcome my coming labor as the perfect one for me and my baby.  I deserve and receive all the love and support I need. I deserve a gentle, natural birth. I claim my birthright for a wonderful birth.  I will be a wonderful mother.

A consensus panel of 15 non-advocate representatives (i.e. not lobbyists) from different disciplines (obstetrics, gynecology, pediatrics, maternal and fetal medicine, midwifery, clinical pharmacology, medical ethics, nursing, anesthesiology, risk management etc. etc.) got together and performed a thorough literature review and listened to presentations by experts, and then drafted the consensus report, posted above.  Pretty nifty, given the amount of information they had to wade through, and the fact that not all of the research available is good research.  I really liked the fact that the statement divides all of its research up into “High Grade of Evidence”, “Moderate Grade of Evidence”, “Low Grade of Evidence” and “Insufficient Evidence”.  My only complaint is that there isn’t actually a reference list at the back of the statement, and none of the research papers they are discussing are actually cited, so it makes it much harder to find and look at the research yourself.

And what does it say?  Basically, that the VBAC rate is still plummeting, and more research is needed.  Big surprise there.  The VBAC rate has been plummeting for decades, ever since its record high in 1996 of 28.3%.  It also seemed to suggest that ACOG could play a much bigger role in encouraging the practice of VBACs again, but maybe that was just my wishful thinking.

The statement begins by systematically reviewing the evidence behind the short-term and long-term benefits and harms of trial of labor v. repeat cesarean from the perspective of both mothers and babies.   Some of the benefits of trial of labor for mothers includes a decreased risk of maternal mortality when compared to repeat cesarean (high grade of evidence).  There is also a lower risk of hysterectomy (moderate grade of evidence), lower incidence of placental complications with future pregnancies, such as placenta previa, and placenta accreta/ increta/ percreta, (moderate grade of evidence), and shorter hospital-stays, with possible decreased risks of DVT (low grade of evidence).  Among the risks of trial of labor for mothers includes incidence of uterine rupture (moderate grade evidence), which is increased if there is a classical incision, i.e. a vertical uterine scar (however, there was only low-grade evidence to support this).  It’s also interesting to note that there was insufficient evidence to support the claim that repeat cesareans help avoid future pelvic floor dysfunction.

From the babies perspective, the perinatal mortality rate and neonatal mortality rate were observed to be lower in babies receiving repeat cesareans as opposed to trial of labor (moderate grade of evidence), and slightly higher rates of hypoxic eschemic encephalopathy in babies receiving a trial of labor (low grade of evidence).

To my way of thinking, though, the more important part of this statement is the fact that it also looked into many of the non-medical factors that are influencing the declining VBAC rate, such as professional association practice guidelines (ACOG’s 1999 Practice Guideline on VBAC being a big one), hospital and health-insurance policies, and professional liability concerns among physicians and hospitals.  I have heard my OB colleagues joke among themselves that the only bad cesarean is the one that isn’t done.  The general outlook that I have observed seems to be that doing a cesarean is always the right way to go from a medical-legal perspective; cesareans are perceived as being safer, by doctors and patients, no matter what the situation, and if in doubt, it’s better to err on the side of doing a cesarean than not.  This attitude can be found all over the place.  To quote a comment made by an obstetrician on KevinMD.com: “You never get sued for doing a cesarean section, you get sued for not doing one. So given the scenario with a questionable fetal heart rate tracing where any “expert witness” can find fault with, (even if there is none) I would rather perform a cesarean section than not. It comes down to a matter of staying in practice and making a living.”

The last Practice Guideline that ACOG has issued on the subject came out in 1999, and reversed its prior encouragement of VBACs, instead saying that women should be “offered” (rather than “encouraged” to have) a trial of labor if there are no contraindications, but basically asserting that it’s a personal decision, and can be decided on between doctor and patient on a case-by-case basis.  The 1999 Practice Guideline also stated that trials of labor should only be done in hospitals ready to respond to emergencies with on-call physicians always available to perform an emergency cesarean, as well as 24-hour on-call anesthesiology coverage (a standard which many rural and smaller hospitals find very difficult to comply with).   It’s important to note that this recommendation was rated as a Level C in the ACOG Guideline (i.e. based on consensus expert opinion, with no hard evidence to support it).  Nevertheless, many hospitals and providers have cited the lack of these emergency provisions as the reason that they no longer offer women trials of labor.

In it’s conclusion, the NIH consensus report directly addresses this issue:

Given the low level of evidence for the requirement of “immediately available” surgical and anesthesia personnel in current guidelines, we recommend that the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists reassess this requirement with specific reference to other obstetric complications of comparable risk, risk stratification, and in light of limited physician and nursing resources.

We now know so much more about the causes of uterine rupture and the safety of VBACs than we did 20 years ago when the practice was first encouraged.  We know that the use of prostoglandin induction agents such as cytotec and cervadil were a chief cause of uterine rupture, and that women with low-transverse uterine incisions actually have a pretty low rate of uterine rupture.  With this in mind, it’s probably time for ACOG to finally issue a new Practice Guideline on VBACs.

A last comment about the NIH report: they left a laundry list of critical gaps missing from the research, highlighting the places where more information is desperately needed, which was nice to see.  They also issued a few choice words about the “cesearean as best defense” mentality:

We are concerned that medical-legal considerations add to, and in many instances exacerbate, these barriers to trial of labor.  Policymakers, providers, and other stakeholders must collaborate in developing and implementing appropriate strategies to mitigate the chilling effect the medical-legal environment has on access to care.

I couldn’t agree more!  Thank you, NIH, for a well-written and informative report.  Maybe this will help swing the momentum back in favor of VBACs again!

Even so, 25 weeks is extremely premature, right on the cusp of viability.  She was moved to L&D this morning because she had begun to contract regularly again, and was feeling increased pressure.  We were able to hold her off for most of the day, but one of the doctors did a sterile speculum exam towards evening in order to visually assess the cervix (vaginal exams are avoided as much as possible when a woman has broken her water, since they tend to increase the risk of infection), and all the doctor saw was a head of hair, without any cervix covering it at all.  A vaginal exam afterwards quickly confirmed what she had suspected: the patient was nearly fully dilated, and the first twin had moved far down into the pelvis, to nearly +1 station.  Initially we thought she might need a cesarean, but a sonogram quickly confirmed the first twin was vertex (obviously…this was the twin that was presenting) and that the second twin was very nearly vertex (more transverse, but with the head still sloping downward).  After consulting with the MFM and attending pediatricians, the decision was made to attempt a vaginal delivery, since one of the risks of extreme prematurity is cerebral hemorrhage in the fetus, and pushing a tiny, head-first twin back up through the bony pelvis in order to deliver through the abdomen was sure to cause more damage, rather than less.  Nevertheless, she was taken to the OR for the delivery just in case a cesarean was needed after all.

All hands were on deck, and the OR was packed.  The attending OB physician was there, the back-up attending was also there, and I was there. We were the delivery team.  Two attending pediatricians, 3 pediatrician residents, and 2 neonatal nurses were also there, divided into two groups–one for each tiny twin.  We had two warmers ready for the twins, two isolettes, two laryngoscopes, two sets of everything.  The anesthesiologist was present and on standby in case we needed to put the patient under general anesthesia for an emergency cesarean.  There were also 3 L&D nurses on hand; one scrubbed and ready to assist in a stat cesarean, and the other two as runners/ circulating nurses.  And a medical student, who was observing (with the patient’s permission)–and holding her hand, and feeding her ice chips.

She was nervous, naturally.  This was her first pregnancy, she’d never pushed before, and she still wasn’t feeling the contractions very strongly (one of the hallmarks of preterm contractions is that they tend to be painless).  We set the sonogram machine next to the patient, and the back-up attending used it throughout the birth to help assess the position of the second twin (twin B), as well as the fetal hearts of both twins throughout the pushing.  We gave her reassurance, helped hold her legs, got her into a good position, and then asked her to push.  Amazingly (well, not really, given how small these babies are, and how low in the pelvis the first twin already was), it took only a few strong pushes before the tiny little head was starting to crown in the vagina.  Before we knew it, the first tiny twin was out, a red little girl weighing only 1 lb 6 oz.  I helped deliver the head and quickly clamped and cut the cord; the attending OB handed the tiny baby to the waiting peds team, and they instantly got to work, intubating and ventilating her tiny little lungs.  She never cried, but she was nice and pink, and waving her little arms and legs around.  Within minutes she was intubated and stabilized, and the team quickly moved her to the NICU.  Meanwhile, we were concentrating on twin B.

The back-up physician was applying steady fundal pressure on the uterus, helping to hold twin B in a vertex position and guide her into the pelvis.  After a few more contractions, the uterus began to close around twin B and push her down into the pelvis.  Once she was engaged, the OB attending broke the second amniotic sac, and we asked the mom to begin to push again, which she did with renewed energy (having gotten a brief rest after the delivery of twin A).  About 10 minutes later, twin B was also crowning, and again, we quickly delivered the baby, clamped and cut the cord, and handed the twin to the second peds team.  She as another tiny little girl, this time 1 lb 8 oz, and again, doing as well as could possibly be hoped for at only 25 weeks gestation.  Once she as stable, she too was moved to the NICU, and the OR began to clear out a bit.

It’s quite an amazing sight, to see two umbilical cords presenting.  We waited for awhile, and slowly the cords began to lengthen as the placenta separated from the uterus.  About 15 minutes after the delivery of Twin B the placenta came out–much larger than a singleton placenta, with two cords and two separate amniotic sacs (di-chorionic/ di-amniotic).  Once the placenta was out, we all breathed a sigh of relief.  A quick exam showed that the woman was intact (not surprising, given how tiny the babies were).  We cleaned her up, took out the foley catheter we had put in just in case she needed a cesarean, and transferred her to the recovery room, where her family was waiting. And there you have it: a remarkably straightforward vaginal twin delivery at 25 weeks gestation.  Not exactly something your average midwife gets to see everyday, but certainly something I felt very lucky to have been able to experience.