Natalia called the doula line at 5:30am, January 1st. Her contractions had been consistently strong for the last two hours, and she was ready to head on in to the hospital and get the New Year’s party started. I met her there at 7am after she had been triaged. She was somewhat disappointed to discover that she was only 2cm dilated, but 90% effaced. With her cervix almost completely thinned out, the doctor decided Natalia could stick around for two hours or so, and if she did not progress within that time limit, they would send her home so she could do her early laboring in the comfort of her home.
We decided to do a labor encouragement circuit. Successful early labor to me is changing what you’re doing every 30 minutes or so, to use gravity, position change, and distraction to encourage progress. Natalia was on board for the position change plan. We walked the maternity ward at Seton, and worked in double hip squeezes during contractions. Natalia sat on the ball and did pelvic rocks. She did standing lunges while leaning on the bed. Natalia and Jason did some slow dancing. Our two hours were up, and it was time for the big reveal. Fail. Still 2cm, but 100% effaced, and Natalia was showing very clear visible signs of discomfort, uncharacteristic for 2cm. So her doctor was still unsure about sending her home, and ordered two more hours of observation.
To kick off the next two hours, I recommended Natalia hop in the shower, the warm water might help her body relax. Jason was on hot water spraying duty and moral support. While she was in the shower, I got on the smartphone to the doula team and told them to send me their best suggestions to treat malpresentation. I had a hunch that Natalia’s baby was in a funky position, probably OP, because her labor was way too intense to be just at 2cm dilation. Sometimes when labor is excruciating this early, it’s because the hard part of the baby’s head is pushing on a sensitive area (like the lower back). And double whammy, when the baby is in a sub-optimal position, it isn’t putting enough pressure on the cervix to cause change. The doula team quickly responded sending a checklist of malposition options for us to try. There might be only one doula in the delivery room, but 9 others have your back when you work with our team.
When Natalia got out of the shower I told her we needed to get serious about turning this baby around. We needed a game-changer position change. So first off, we did a sidelying pelvic floor release, to reset the pelvis and create some more room for baby to rotate. After this Natalia got into child’s pose, having her butt up in the air would allow her baby to disengage from the pelvis (in the hopes it would re-engage in a better lie). Then it was hands and knees positioning as long as Natalia could bear it (hands and knees can be tiring on your knees, back and neck). Hands and Knees allows the heaviest part of the baby (head) to rotate down, the most optimal position for labor and delivery. While she labored on her hands and knees, I got behind her to do some double hip squeezes during contractions (which also helps to open the pelvic outlet). Between contractions Natalia appreciated long massage strokes on her back to help her dissociation/meditation techniques (her mind was in an outdoor rainforest shower in Belize, her happy place). Going back and forth between child’s pose and various hands and knees positions, suddenly something changed, and the stabbing shooting back pains had vanished. Yes! A good sign that changing positions was working.
At the next cervical exam around 12:30pm, Natalia was a solid 4cm, and 100% effaced, and a zero station! Baby had dropped, cervix was stretchy, back pains were gone, full steam ahead! Natalia exclaimed “I think we actually turned her!” During the earlier back labor Natalia was dreaming of an epidural (but knew it was too early to request it). Now, at 4cm, her nurse A-OK’d whatever she wanted. But, the game had changed, now that this baby was in a better position, the labor became tolerable again. Natalia was glad to hear the option was available, but wasn’t quite ready to request it. Shortly after this discussion Dr. Yium was doing her rounds, and Natalia picked her brain about getting the epidural. She wanted to rest, and was worried about increasing intensity or returning to back labor land. She was also worried about waiting too long and missing the epidural window. At the same time she didn’t want the epidural to slow her new found progress. Dr. Yium decided she would check Natalia herself, and depending on how her cervix felt, would be able to better advise her. Her check within 30 minutes from the last exam revealed a cervix 5-6cm, Dr. Yium was confident that labor was moving at a good clip and an epidural wouldn’t interfere. Natalia wasn’t totally ready for an epidural, but was happy to hear that if she made this decision her labor would continue moving forward. She decided to do everything she needed to do to be ready for the epidural in the case she decided to opt for it, which included getting a hep lock and a full bag of IV, and getting her blood work done. These things take about 45 minutes to accomplish, so she kept powering through the increasingly intense contractions on her hands and knees, and rested in between in a seated position leaning back on the birth ball on the bed.
By around 1:30 (an hour after “active labor” officially started), Natalia was feeling the urge to push, and pressure in her bottom. The nurse checked her and was surprised within 30 minutes Natalia had gone from a 5ish to a 9ish. She would probably be complete, except that her bag of waters was still intact and bulging. Holy Transition! Dr. Yium suggested breaking the water, this might be the last push to bring that baby down and cervix completely dilated. Natalia agreed to this plan, and after the AROM, Dr. Yium said there was a tiny cervical lip, that Natalia would have to wait it out before she could push in earnest.
9.5 cm kicks butt. But it’s also the most intense part of labor, the very end of transition. Natalia had made it so far! I was so proud of her, as was everybody in the room. I knew she could do this thing unmedicated, no sweat. But Natalia was still waiting for her epidural. I encouraged her to go without it, and said, if it’s your goal to go natural you’re almost there. Then she reminded me, that wasn’t her goal. Right! Time for me to change my position! She had always intended to get an epidural, and that was still her intention. She didn’t need me to persuade her otherwise, that wasn’t my job. As soon as she got the epidural there was an immediate calm and peace over the room. Natalia finally was able to rest comfortably, something she had been wanting to do all afternoon, and 9.5cm really was her first opportunity to do so.
Dr. Yium allowed her to labor down for half an hour or so, and then it was time to push this little lady out. Natalia was a trooper pushing hard for a good 90 minutes. The position that seemed to work the best was when Jenni (my shadow doula extraordinaire) held the rebozo at the base of the bed and Natalia grabed on it with both hands to pull herself toward Jenni and use that momentum to direct her strength down. Jason was in charge of keeping Natalia energized and comfortable, supporting her head, cheering her on, applying the chapstick, and catering to her ice chip and apple juice needs. I was on warm compress duty to help that perineum stretch. 90 minutes of pushing had her baby right on her perineum, but still a little stuck under her pubic bone. Her baby was showing some signs of fatigue, as was Natalia, self-admittedly. Dr. Yium suggested using forceps to help nudge baby around that corner. Natalia would still have to push hard, and Dr. Yium would just steer. One push later, at 4:33 pm Natalia’s beautiful baby girl was placed on her chest for some immediate skin to skin time and pinked up and cried immediately. Dr. Yium let her hang out there while she waited for the cord to stop pulsating. Jason got to cut the cord. Baby girl (who’s name is still being contemplated) was a tiny peanut, and weighed in at 5lbs 7oz. She was quickly weighed and measured, and went straight back to mamas chest for more skin to skin time. Natalia got a full 2 hours of bonding and breastfeeding in without interruption (thanks Seton!) And another pleasant surprise was that her mother, fresh off a plane from Kansas, excitedly arrived within minutes after baby’s birth, teary eyed and cooing at her brand new baby grand-daughter.
I thank you Natalia and Jason for allowing me to take part in this beautiful day. I thank you for always being open to changing your position. And reminding me to do the same. Many blessings to your new family. AS.