Something important to care about

(Originally posted August 1, 2006)

Instead of my normal trivial paranoia, something real to be thoughtful about today.

Someone I love very much is in labor. Whatever you do...vibes, good thoughts, light a candle, say a prayer, visualize opening and bringing forth the baby to arms of love....please do.

Hilary

Days five and six...sleep is for the weak

Pet mom wasn't the only woman at the birth center that evening. Our VBAC (Vaginal Birth After Caesarean) client was back. She was over her due date by a few days. VBAC clients are more sensitive than other moms, since they are at a higher risk for certain complications. She had already consulted with our doctor back up, had extra ultrasounds, a biophysical profile on the fetus, and a Non Stress Test (NST).

Even with all of these diagnostic tests at our disposal, and with studies showing success rates above 90% on trial for labor for VBAC attempts, many practitioners and hospitals do not allow women to choose to try for a VBAC. And, even with all of those diagnostic checks at our disposal at the birth center, we can't deliver a VBAC mom if she doesn't go into labor if the first place.

We had been trying to gently nudge VBAC Mom into labor using safe midwife tricks. She had been at the birth center on and off for days. We had her inserting evening primrose oil suppositories; we put her on the breast pump, and then had her pacing up and down the parking lot. Finally, she started having contractions. From early afternoon, all through the night, to the next morning we monitored her vital signs and the fetal heart tones. The midwives only did a few vaginal exams.

Unfortunately, she had still only dilated to three centimeters after almost a day of contractions. The same thing happened during her first labor. We gave her the option of trying to wait longer, or to go to the hospital. She chose to go the hospital. It seemed unlikely she would dilate any farther.

This is when things turned from bad to worse. Sometimes the doctor takes plenty of time to show up to the hospital when it is a non emergency caesarean. In the meantime, I stayed with the increasingly frustrated VBAC Mom and her partner. For five hours, we were left practically alone in the room. Our nurse apparently got called to assist an emergency caesarean section, but we were never told.

I tried to find a nurse when VBAC's Mom's fetal heart tones repeatedly dropped after contractions. I politely asked for a nurse at the desk, which was occupied by a lone receptionist. Apparently the pressure of being understaffed during a stressful time is enough to make certain nurses lose their cool. The only nurse on the whole floor pulled me aside and threatened to throw me out of the hospital for "antagonizing" her for asking her to check on VBAC mom. When I asked her a few minutes later if someone could please change the rapidly dwindling IV bag, she snarled from her paperwork "Can't you see I'm busy?" and never tried to call another nurse.

Luckily for us, our nurse who had disappeared for the emergency caesarean showed back up soon after, and showed amazing compassion and professionalism, unlike her stand in. I was shocked, considering how I usually had such wonderful experiences with the nurses at this hospital.

VBAC Mom had a hard time waiting for the doctor to show up. It is hard enough making it through contractions when you know they are dilating you to a goal. She knew hers weren't. She was very frustrated, and had a hard time dealing with the antagonistic nurses, and then the defensive director of the floor, who came down to the room twice. The director was trying to make up for the lack of attention and shoddy treatment from the nurse, but just came off as harassed and defensive. Or, she was coming to investigate my supposedly antagonistic behavior. She was sadly disappointed if that was her goal.

I returned twice after VBAC Mom had a successful surgically delivered beautiful baby boy. I have never seen a boy refuse to open his mouth like this kid! When VBAC Mom complained over the phone she was having latch on problems, I figured both she and the baby were just a little worn out from the prolonged labor and the surgery. But, when I showed up, this boy had his gums locked together like I have never seen. Even if he got frustrated and cried from our fussing and prodding, he wouldn't open his mouth.

"See?" said VBAC Mom. "My daughter latched on right away, no problem."

It was really hard to get her nipple in the little opening this boy would give us, since it seemed to flatten out when she cupped her breast to offer it to the baby. I asked the nurse on duty if they had any nipple shields. I got another defensive reaction. The nurse berated me, "Do those look like flat nipples to you?"

VBAC Mom, who had been trying to latch on for about a day by this point, tried again right in front of the nurse. Her nipple flattened out and the baby closed his mouth. VBAC Mom had already given him formula once. No one had suggested pumping to her. I was afraid of both of them giving up on the breastfeeding soon. The nurse looked for nipple shields, but couldn't find any. I went back to the birth center, and brought back nipple shields and a hand pump.

It took at least another half an hour of wrestling with this poor boy to get him to latch on, and then to get him to suck! Luckily, VBAC Mom was already producing lots of milk. We hand expressed some into the tip of the nipple shield, and got the baby to latch on to the shield on the tip of my finger. I tickled the roof of his mouth, and got him to suck. He got a taste of the milk, and something clicked.

"Breastfeeding is a learned behavior," I explained to VBAC Mom. "He is just not getting why we are trying to force him to suck this thing..."

We expressed more milk into the tip of the shield, and then got him to latch on to the shield over VBAC Mom's nipple. He latched, and he sucked contentedly.

"Is he on? Is he sucking?" I asked excitedly.

"I think so...ow! My uterus!" said VBAC mom.

I smiled. Afterbirth contractions are stimulated by effective sucking, and so is the feedback to the brain to encourage more hormones to produce more milk. He continued to suck for 20 minutes.

I told VBAC Mom to call me if she needed anything else. I made an effort to thank the nurse profusely for being supportive of breastfeeding, even though she seemed impatient and dismissive earlier. I told her I realized she didn't have the time to struggle with this kid to get him to latch on, and that I was ready to come back at a moment's notice to help. We need a good relationship with the nurses at this hospital so our transferred moms feel supported and we are welcome there.

VBAC Mom will still keep her postpartum visits at the birth center, and we will put her Polaroid up on the wall with the rest of our moms.

Day five - the pet

Sometimes midwives have pet patients. We have a large, busy birth center with a team of midwives, midwife assistants and students. Although one benefit of midwifery is supposedly more one on one attention, we do advise all of the clients to get to know all of our midwives. None of the midwives try not to promise any mom that she will definitely be at her birth, because she may have been on the night before with another mom. However, sometimes a midwife forms a special connection with a client, and tries to be at her birth no matter what.

Often it is a relative, or a close friend. My closest friend is moving down here soon, and is in her second trimester. She will be my pet patient, and I will try to be at every appointment from her initial visit to her birth and through her post partum checks.

Sometimes it is just a client who forms a close relationship during her pregnancy. This was one of those clients. Even though midwife C wasn't scheduled to be on that night, she stayed with her pet client, who was a first time mom.

This Pet Mom and her boyfriend didn't look like they would be friends with C outside of the clinic. Both of them had dark brown skin and long, delicate dreadlocks. The dad is a musician. He canceled a gig that evening, and his guitarist was sitting in the waiting room. They were funky and hip. C is older, a grandma several times over, with silver hair and pale wrinkled skin. She is anything but funky and hip, with her office full of Precious Moments figurines.

Pet mom had a beautiful labor, and had a waterbirth. Her boyfriend joked with us between contractions. He said he was going to let their boy make up his own mind if he wanted to dread his hair.

Once the baby was delivered, the mom, dad, and new baby moved to the nearby bed. C chided the dad that he had to marry the mom now. I held my breath, wondering how the couple would respond. He said "C'mon, that horse has been dead at least four minutes now." Pet Mom was just beaming, and didn't seem to notice. She was just grinning and saying "That was great!" before her placenta was even out.

I saw the Polaroid on the wall the next day of the family on their way home. Pet mom was wearing a Wonder Woman T shirt. Wonder Woman indeed! The wall is full of superheroes.

Day four, baby catcher!

We had another beautiful birth, and this time, I was catching! A "four-handed" catch, with the midwife's hands right there with me, and another midwife in the room, but still a catch. It was a great labor and birth. Number five for this mom. Number two for me.

She hung out at six centimeters for what seemed like forever, although it was only a few hours. Her waters had been partially ruptured (there are two layers of the sac) for over 12 hours, and she had to deliver within 24 hours by law or we had to transfer her. Her last labor had been the same, and the baby showed up suddenly just before the 24 hour mark.

She was in great spirits. Whatever she needed to do to keep her contractions going, she was willing to do. Unlike most moms, the walking didn't seem to speed up her contractions, but rather slowed them down. That was fine with her and her husband, because they would much rather watch movies in the room than walk around the grounds in the heat and fight off the mosquitoes. Between midwifery school, work and my two kids, I don't get to catch a lot of movies. I got to catch up on sections of a few while I was doing her labor checks and coaching her.

We checked her and confirmed she was six centimeters still, but then the tide seemed to shift. Tide? More like a tidal wave. Her contractions came on with amazing intensity, and seemed to lengthen and get closer together with each one. This mother who was so calm, and barely changed expression with her contractions suddenly got wild as they came on. She started screaming "I NEED TO PUSH!! I NEED TO PUSH!!" It had only been thirty minutes since her last vaginal exam.

The midwife said checked her and said she was complete! Four centimeters in half an hour!

"Call Shari!" she said. "And put on your gloves!" I made a quick phone call to Shari, who appeared from the other building within seconds. I moved over the table with our delivery set up, and started asking the midwife if everything was arranged correctly. She said "Hilary, come here!" in an irritated voice. I turned and looked at the mom, and saw the first part of the baby's head emerging. A few pushes later, and I was gently pulling the baby up to her chest. Minutes before the twenty four hour deadline.

When a mom has a fast transition, it seems to me from the outside like she has a hurricane going on inside of her. Just like I don't know what that incredible "urge to push" feeling is like because I have never felt it, I have also no idea what a fast labor feels like. One of the other midwifery students had one long labor and one very quick one, also known as a precipitous labor. She said the faster one was way too intense, and preferred the longer labor. I personally think that's nuts, having two extremely long labors myself, but I really can't say since I have never experienced it. But, from the outside, I guess I can see her point. These women seem to be especially affected by their contractions, and have less time to recover, but they have the benefit of the whole experience not lasting very long.

Day three...well, technically, day four

I wanted to check in before now, but I have been at three births, one clinic, and actually got to sleep for about 6 hours. Not bad for almost 72 hours.

I wish I could say the homebirth was easy and beautiful and idyllic. If this was fiction, I would have laidthe foundation of the perfect situation, the wonderful couple, the right support system, and then the birth happens the way we all wanted, and I made my point about natural birth. Don't get me wrong, the labor was probably the most fun I have ever had at a labor, and that is saying a lot for being up for a day and a half. However, the birth was hard, and it shook me pretty deeply.

The most important of the physiological changes in labor to allow for a vaginal birth is the a dilation of the cervix. "10 centimeters. Complete." Those are the magic words that every woman who has suffered through labor is longing to hear. Homebirth Mom was having great contractions, which is one mechanism that encourages the cervix to dilate. However, Homebirth Baby was coming down with her little head a little cockeyed. The pressure of the baby's head against the cervix also encourages the cervix to dilate, but a crooked head does not descend or dilate well.

The labor was long. None of us, least of all the mom and I, got much sleep. Her spirits remained astonishingly high. She danced, she laughed, she played between contractions, and she focused and breathed through them. However, her dilation stalled and stalled. Finally, her cervix was almost complete. However, one portion of it stubbornly remained thicker than the rest. This is known as a "lip". It is rare, it holds up the transition from labor to pushing, and I had one during my first labor with S seven years earlier.

I watched as the midwife rubbed out the cervix with her gloved fingers as the woman screeched and moaned. Homebirth Mom never pulled away, she never sobbed "NO! No, please stop, it hurts SO MUCH!" as I remember doing. I had a day long labor too, but I was in a cold hospital room, strapped to monitors and with an IV full of pitocin to make my contractions harder. No epidural, no best friend, no doula with lavender aromatherapy spritzer, no team of midwifery students. One midwife with the bedside manner of Dr. Frankenstein, one labor nurse who was wonderful, but who I had never met before, and my shell shocked husband and mother who were not that into the natural birth thing.

Homebirth Mom endured the midwife manipulating her lip for a good two hours. It took my midwife about three and a half hours to get rid of mine as I pushed and screamed. My mom kept waiting for the nonexistent doctor to come in, put me under and take out the baby.

When I graduated from high school, I initially became an education major because I was so disgruntled with my high school administrators. I switched to being a fashion design major because I hated the way the mainstream clothing industry seemed to not be able to make cool yet comfortable clothing. I was suddenly afraid I was training to be a midwife because I hated the way my first birth went, and I thought I could (eventually) do better than my midwife. But apparently, midwifes rub out cervical lips. Some of them, including the one at my center and the one who attended my first birth, did so with no anesthetic or ice or anything. And it hurts the mom. Would I be able to do that for a mom while she screamed and I flashed back to the intense, excrutiating pain I felt?

I sobbed as I drove a car full of homebirth supplies and the placenta back to the car. Oh wait, you wanted to hear about the birth. The baby finally came out, and was perfectly fine. The mom and dad were ecstatic, and I am sure they do not regret their choice of having a natural birth. She may even have another baby and may choose to do it naturally again, as I did. But I was shaken to the bone. I was thinking how an epidural would have probably been pure mercy for her, and for me. However, about 5 % of moms have persistent lips like that. I have probably only seen a midwife have to rub out the cervix on a screaming woman twice in the roughly 50 births I have been to.

So, without my crystal ball, I will not be able to predict who will have a lip, or any other complication. I got to see two more births today, after a solid six hours of sleep and a lot of thinking. I love talking with moms and doing prenatals. I love the post partum checks with the brand new babies and cheery but sleepy new parents. Believe it or not, I love the labors, even the long ones. And I love the easy births. And the medium births. It's the hard ones that really shake you. Especially if they remind you of your own. But, that's OK. It's not really the easy births that women really need midwives for anyway. As Shari says, most of those babies would eventually fall out on their own anyway.

I wouldn't go back in time and choose an epidural for my first birth, and I really doubt Homebirth Mom would either. And women who are willing to take the hard road need midwives who are willing to walk with them. I hope to be that one day.

Day two...a surprise at lunch

We were all sitting around a delicious lunch of falafel, hummus, tabouleh, and pita, including Homebirth mom. She was definitely feeling the contractions more now, and was moaning softly through them. In between, she joked with her dog and friends, and ate a sandwich. She was so hungry and grateful she was not in a hospital, where they would hook her up to an IV and starve her feed her only ice chips for her marathon labor.

One of the only unwelcome surprises of the labor was the appearance of Mom of Homebirth Dad. She apparently did not know Homebirth Mom was in labor, or that they were planning a homebirth! Luckily, Homebirth Dad did some MAJOR diversionary tactics. Homebirth Mom stayed comfortable on her birth ball at the table, and Homebirth Dad discreetly shuffled his mother out the front door with a hurried explanation. After a few minutes outside explaining to her why she could not join in the festivities, he returned to sit at the feet of his wife. I am so impressed he didn't bow to his mother's pressure and let her in to where they had decided she would not be helpful.

I am all for having relatives at a birth if they are a positive presence. Homebirth Mom's mom has been a remarkable calm and loving support throughout the entire labor so far. Moms of women in labor tend to be the most supportive or the most fearful and emotional. I am glad Homebirth Mom and Dad seemed to pick the right mom to be at the homebirth!

Day two...no sleep, but at least I'm not the one in labor

Homebirth mom called us back at 2:45 am. (Wouldn't you know the phone started ringing JUST as I turned off my computer and decided I would take a stab at sleeping on one of the couches at the birth center? I am definitely going to have to get over my problem sleeping anywhere other than a bed in a dark room with perfect quiet.) Her contractions had picked up to one every five minutes. Maribel and I got into our cars and headed back over to her house, this time possibly to stay.

We were pleasantly surprised when we arrived that Homebirth Mom, Homebirth Dad and Mom of Homebirth Mom had honestly tried to get some sleep after we left the last time. That can be incredibly hard when you are having contractions every 10 minutes and are extremely excited about having your first child. It is even harder to look back after hours and hours of contractions coming much closer together than ten minutes apart and to wish you could have just taken that two hour nap.

Maribel checked Homebirth Mom, and announced she noticed significant progression since our last visit, with effacement (thinning of the cervix) and dilation (opening of the cervix.) We were there to stay, and she went to call Shari to report the results of the exam, and to call Carol, the midwife who would be attending the homebirth.

It is now just after noon, and I have to say this is one of the most wonderful labors I have ever been blessed to witness. Homebirth Mom, Homebirth Dad, Mom of Homebirth Mom, the doula and her best friend are an incredibly positive and cheerful bunch of people. It is so refreshing to see a woman who has a long labor maintain a consistently positive and relaxed attitude.

No, she didn't have the four hour labor her mother had years ago in Rome. But, she didn't find out she had only dilated one centimeter and a half after four hours of natural labor and burst into tears and insist on being sent to the hospital for an epidural either. It breaks my heart when mom with all intentions of going natural gets a "bad grade" on a vaginal exam and all of a sudden "can't handle" the contractions that she was breathing through with no problem five minutes before the exam. I fully understand the disappointment, having a 24 hour and 36 hour labor (yes, the second one was LONGER...) under my belt. But, Homebirth Mom smiled, stood up, and went to dance to Bob Marley and Barry White with her best friend, mom, doula and Chihuahua .

Unfortunately, we are on a ticking clock since her waters are broken, which leads to increased risk of infection and a mandatory transfer after a certain amount of time in Florida. I will check back in with an update on how the remarkably accepting and upbeat Homebirth Mom does. So far she has had two hours of sleep, more than 12 hours of labor, no drugs except for the antibiotics we gave her, two peanut butter and jelly sandwiches, several cups of Gatorade and raspberry leaf tea, and an endless supply of joy and support from her remarkable labor posse.

My many hats

Every now and then, I will be taking off my tinfoil hat and putting on one of my many other hats: mom, friend, cook, feminist, midwife in training. This week it will be my midwife student hat on my head.

I am training at the Miami Maternity Center and International School of Midwifery, the same place where I gave birth to my younger son Z. It is a grueling but beautiful program. I get to be part of some of some of the most memorable and emotional experiences of women's lives. I also get to catch vomit, mop floors, inspect placentas, and dipstick urine, sometimes at 2 o' clock in the morning. Sometimes I wonder what is harder, giving birth naturally or midwifery school.

Especially this week. Tomorrow starts my "Hell Week". In our 3 year program, we are required to spend one full week at the birth center in our second year, and two full weeks there in our third year. We have to attend every birth, every clinic, every class. We shadow the director and ignore our families.

It is the albatross around the neck of every student in the program, and it is especially hard on those of use who are parents. I have so much to do - pack clothes, pack food, pack a sleeping bag. All I want to do is run away and hide. I know if I worry about sleep deprivation, missing my kids and husband, or the amount of work and cleaning I will be doing, I will make myself miserable. OK, more miserable. I am really looking forward to the experience and all of the moms I will meet and births I will see, but I am going to have a hard time leaving home tomorrow morning.