Pampered Pregnancy – Blissful Birth

Roslyn* called around 7pm to let me know that she thought her water had broken.  She wasn’t having any contractions yet, but did head over to the hospital to confirm her suspicions.  Her water did indeed break, but she decided to wait until her contractions picked up before she wanted me to join her and her husband at the hospital – this gave them some time to get checked in, and get settled in to their delivery room.  By 10pm her husband Neil called me with an update, indicating that contractions had indeed started, and that they could use my support.

I whisked over to the hospital and found them in their room working through a contraction.  Roslyn found it most comfortable leaning against the wall while Neil offered some counter pressure on her lower back.  (He remembered what he had learned at our prenatal comfort measure appointment!).  Roslyn was smart to ask for a hep lock and a mobile telemetry monitor, which offered her complete freedom of mobility.  To use gravity to our advantage to improve Roslyn’s dilation from 2cm, we decided to walk the halls of the L & D unit.  They have a lovely circuit set up where we could walk continuously around the nurse’s stations at either side of the maternity ward.  We learned that the entire circuit took exactly two contractions.  After many loops Roslyn decided that she was getting pretty tired, and didn’t want to wear herself out for the upcoming labor and pushing ahead, so we went back to the room to try some other gravity friendly positions.  We tried hands and knees, birth ball, and some sitting positions – contractions at this point were getting more intense, and closer together. Roslyn moved to a seated position on the bed, Neil helped her relax by massaging her shoulders, and I worked on bringing her attention to her breath by counting out 10-12 breaths for each contraction.

At 12:30 am Roslyn decided it was time to get an epidural.  Her birth plan included the epidural option, she had wanted to see how far she could make it on her own.  After making the request for the anesthesia we learned that the only anesthesia physician attending in L&D was currently in a C-section, so we’d have to wait until they were done.  Roslyn was slightly distressed, but realizing there was nothing we could do about it she kept working through each contraction by closing her eyes, and focusing on her breath, while I counted each contraction out for her as a distraction technique.  We did this for about 90 minutes, and the anesthesiologist walked in like a breath of fresh air.  Roslyn had some anxiety about getting the epidural, but the anesthesiologist was confident, precise, and fast; and before she could even build up concern, he was done and she felt relief from the contractions within minutes.  Since Roslyn’s membranes were ruptured, she wasn’t having too many cervical exams conducted, but by 2am after the epidural was administered she was near 6cm and 75% effaced.  She had worked very effectively on her own before the medicine and progressed 4cm in those 4 hours.

Once Roslyn was comfortable (pain wise) I noticed that her husband breathed a huge sigh of relief too.  At this point he could barely keep his eyes open – having dealt with all the stress and anxiety to get to this place.  Roslyn and Neil had tried many years to get pregnant, with multiple fertility treatments and a previous miscarriage, this had been a long road.  He promptly curled up on the pull-out bed and crashed hard.  Roslyn commented that at home he needed dark and quiet to sleep.  Here in the hospital room it was neither, but that didn’t seem to bother him.  Roslyn felt very happy with this – it was an indication to her that Neil felt relieved and felt confident that Roslyn was in a good place, and had good support.  Now that Roslyn had her epidural she was more relaxed, and we spent the wee hours of the morning discussing the next phases of labor, items in her birth plan she wanted me to advocate for, breastfeeding and babycare, and of course other non-birth related gossip.  Roslyn often stays up late, and she was too excited to sleep anyhow.  Our night nurse Lisa was lovely.  It turns out that she only had one other patient, who was probably sleeping, so she spent a lot of time in our room chatting it up about her various husbands, how she lost 100 pounds on the swine flu diet, and gave us the code to the “good” snack room.

The time flew by and at the 7am shift change the new L&D nurse came on duty and did a cervical check to get an update on Roslyn’s progress.  She was now about 8cm and 100%.  Things were looking very promising.  Another check on the doctor’s round at 11am and she was 9cm.  She had a cervical “lip” and some swelling.  She would be 10cm except for this nasty lip that wasn’t going away.  At 12pm, still at 9cm with lip, the doctor was showing some concern.  A normal labor progress curve is a slower dilation from 0-5 cm, and after that you see dilation move at a much faster rate.  Being that Roslyn’s labor was doing the opposite, he was concerned about her uterine dystocia.  Before moving on to more serious interventions, he inserted an intrauterine pressure catheter to determine if Roslyn’s contractions were strong enough on their own to be able to complete her dilation.  After he left, Roslyn started to shed some tears.  She was coming to terms with the fact that a c-section was a likely outcome.  I told her to stay strong, that time was on our side, and things could still turn around.

After an hour on the IUPC, it turned out that contractions were fairly strong, but could be stronger.  So doctor’s diagnosis was that it was either 1.  Big baby  2.  Small pelvis 3. Malpresentation. 4.  Weak contractions.  He said there wasn’t anything he could do about 1, 2 or 3, so the options were to either add a low dose of pitocin to see what might happen, or to move to the OR and proceed with a C-section.  Roslyn had some concerns about pitocin – her baby’s heart right was slightly high, and Roslyn had a slight fever.  She felt if the pitocin regime caused hyper stimulation of her uterus it would cause more distress to her baby and move her from scheduled c-section to emergency c-section.  She was also concerned about continuing to labor since the “24 hour time limit” since water broke was approaching and if she had to get a c-section anyhow at that point then might as well just do it now.  The on-call doctor for her practice, Dr. Phillips of Austin Area OBGYN (we’ll call him “Ken” for the sake of the story) is my new favorite from that practice based on his answers to Roslyn’s concerns.  He said that there was nobody more concerned about the health of their baby then he was, and he wouldn’t recommend pitocin if he thought it would be detrimental.  He was not concerned about that elevated heart rate – since it was consistently elevated from early labor, he thought baby just had a higher baseline, and since he didn’t see a pattern of any late decelerations or other indications of baby not tolerating labor he was not concerned.   He also said more than once, “the last thing we want to do is rush to a c-section”.  Finally he said “There is no clinical significance to the 24-hour deadline for delivery after water is broken.  As long as you and baby are healthy, you can continue to labor as long as you need to.  We just need a plan for this uterine dystocia.”  I loved this – he is totally correct about that time frame (recent studies have come out indicating that there are no differences in rates of infection between those delivered within 24 hours, and those that just wait it out).  Also, he built up confidence in Roslyn by giving her options while at the same time did not force her a direction she didn’t want to go.  Finally – he said she could try low-dose pitocin – and if there were any negative effect, they would shut it off immediately.

Seeing that “Ken” was making the pitocin regimen as safe and as minimally invasive as possible, Roslyn decided to try that option first before going to a c-section.  The doctor wanted her to give pitocin an hour to have effect.  But number 3 on his diagnosis list was still nagging at me.  It seemed pretty clear that Roslyn’s baby wasn’t in a perfect OA position – she was having a stalled labor and her cervix was swelling prior to pushing and had an anterior lip, both indications of an OP baby.  In the natural birth world, if you have an OP baby, you change positions to help use gravity to get that baby to turn.  Hands and knees works wonders.  I asked the nurse about position options, but since Roslyn had an epidural she felt we were limited in what we could do with positioning.  In a lucky turn of events, this assigned nurse had been called to another room for a delivery, and Roslyn got a new nurse, Barbie (yes that is her real name).  The first thing Barbie asked when she walked in was “Have you guys tried hands and knees?”  We asked “Is that even an option?”.  And she said “Can you move your legs and bear weight”?  Roslyn said “I don’t know but I’m willing to try!”  As a doula – I’ve always been told that hands and knees is not an option for medicated mamas – but Barbie has rocked my world by proving that it is.  She said as long as you are on the bed, you can technically do whatever you want.  Dad, Barbie and I all helped Mom flip around and maneuver into a hands and knees position on the bed.  Her epidural was perfect – took away all of the painful sensations in the uterus, kept pressure in the pelvis, and maintained good feeling in her legs.  I hopped on the bed and started rocking her hips back and forth and in circles.  With gravity helping us, and having an open pelvis with the rocking, we were hoping baby would turn thus completing dilation and avoiding a c-section.  We had an hour to prove to “Ken” that we could do a natural delivery.  After being on hands and knees for 15 minutes or so Barbie kept us on moving by flipping Roslyn to her side for 15 minutes, to the other side for 15 minutes, and then back up to hands and knees for 15 minutes again.

I'm rocking Roslyn's hips to rotate that baby from OP to OA

Near the end of our pitocin happy hour, Roslyn was feeling the urge to push (another benefit of her light epidural).  Doctor “Ken” came in to check her, and confirmed that yes, Roslyn was at 10cm, the lip was gone, the hands and knees work and hip rocking (and pictocin) had worked to avoid a c-section.  At this point baby was low enough for Roslyn to push out and the OR staff was off notification.  Barbie, Roslyn, Neil, and I almost cried in relief that Mom would get to birth the way she had wanted.  I truly think the nurse change-over saved Roslyn from a C-section.  Dr. “Ken” bid farewell and said “see you in a few hours – you guys work on getting this baby out and call me when she’s crowning”.

Barbie again proved to be a rockin’ nurse, seeing that Roslyn had great mobility she suggested doing some gravity-friendly pushing positions as well.  Roslyn took turns pushing on her side, on her back, on the other side, and back again.  We even brought the squat bar out, and Roslyn tried a few pushes in a squat.  She felt the side and back positions were better for her, but the squat bar was actually a great place for her to rest her legs in between contractions.  Roslyn used the mirror for pushing too, and noted that this was a huge motivation for her and reinforcement for her to know she was pushing to the right place.  Roslyn was pushing effectively, but after an hour or so she was getting a little tired, and was having pain in her lower back and hip areas.  So between each contraction I got in there and provided heavy counter pressure on her hips and back with my full body weight and my fists.  Because she was pushing on her side I had complete access to do this for her and she said it was a big help in relieving the pain.  In a final effort to get baby to crown I pulled out a rebozo (traditional Mexican midwife scarf).  Roslyn held it on one end, and I was at the foot of the bed bracing myself and holding the other end.  With each push she pulled herself towards me with the rebozo.  This had the effect of concentrating her force down, and curling her upper body around baby to improve baby’s movement.  Within a few pushes we had hair, head, and had to call the delivery team in to catch baby.  Once the team was in place, Roslyn pushed twice more, and baby was out, pink, screaming.  Neil wasn’t keen on cutting the cord, but Roslyn asked if she could do it, and she did!  It was the first time I had seen mom cut the cord and it was very cool.  Their long-awaited baby was born at 5:52 PM on the due date no less.

Allison was the nurse assigned to baby at the time of delivery, another of my favorites at NAMC.  She is also studying to be a CNM, so she is very fond of midwife style birth practices.  She allowed Mom to keep baby on chest as long as she wanted, and did all of the medical examinations within Mom’s view, and had baby back to chest within minutes for full skin to skin bonding.  The nurses also offered to delay the bath a whole day so that baby didn’t have to stay for a prolonged period in the nursery without mom.  They also said that since Roslyn had such great mobility that they would be most happy to remove her epidural immediately, and wheel her anywhere she’d like to go so that she wouldn’t be separated from baby.

Many of the choices Roslyn made are not often standard with birth at a hospital.  (no imposed 24 hour labor limit, hands and knees laboring with an epidural, side lying pushing, no separation from baby at birth)  Because Roslyn had a well thought out birth plan and made her requests know to her nurses and doctors, and because she had an awesome team at NAMC, (aside from a close-call c-section), she was able to realize her birth plan wishes, from start to finish.

*Mom preferred to remain anonymous, but allowed us to post this birth story with the names of her and her husband changed.