Babies

This week I had the pleasure/opportunity to participate in two births.

Both were fairly straightforward . . . mostly, but not entirely . . . and the babies were a little more challenging than I'd like.

The first was a first time mom who was 42 weeks. She'd been in to see the OB, who gave her the all clear to have her baby at the birth center because she was finally in labor! She labored for about 10 hours, and after 2 hours of pushing quite effectively, we opted to give her an episiotomy because her vaginal tissue would NOT stretch, and she was tearing further down her perineum. The baby was starting to have trouble, too, as she had been almost born for quite a while. As soon as the cut happened, the birth was within about 30 seconds. Finally!

The little girl went to her mom's chest, and overall looked good. She pinked up nicely, had good tone, and her heartrate was normal. However, her respiratory rate was high, so we watched her closely as she transitioned to life outside the womb. She did okay for a while, first held by her mom, then dad, then mom again. She was put to breast around 30 min of age, but didn't seem really interested in feeding. It broke my heart when the mom said, "she doesn't like it!" After giving it a good college try, including stimulating her, switching breasts, etc, I finally said - "anyone else have any ideas? She's just not that interested in eating." The midwife said, "Breastfeeding is a vital sign, so if she's not interested, it could mean that something is wrong."

The midwife took the baby, and did another evaluation. She was now almost 90 minutes old, and when we turned the lights up higher, it was clear that her skin was not quite as pink as we'd like, but more dusky. She also started to have retractions, meaning that she was putting a lot of effort into breathing. She hadn't been doing this on mom's chest. First we suctioned her, and then gave more oxygen, which did pink her up quite nicely. But her respiratory rate remained high. More suction revealed some blood in her throat, strangely. She'd sounded "juicy" and been spitting up "gunk" for a while, but it was all clear . . . until now. Not good. We recommended to the parents that we send her over to the NICU for more observation, so as soon as we'd copied records and called ahead, she was on her way.

According to the neonatologist, that night things were "touch and go" with her - she was put on a respirator with 100% oxygen. Fortunately, about 36 hours after her birth, she was improving in all ways measureable. They were calling it "blood aspiration" at the hospital, which really didn't make much sense . . . because the birth wasn't really bloody. So it's possible she had a pulmonary bleed. Why? No one will ever know. Maybe a familial clotting problem, or maybe a fluke.

Meanwhile, when we sent the Dad and the baby to the NICU, we stayed to complete the care for the mom. She was exhausted! We had her eat & drink, and then get up to go to the bathroom - all requirements for discharge. After sitting on the toilet for a minute, she got very lightheaded and almost passed out. We had her lying on the floor of the bathroom with oxygen on her, too. What a mess! After a while, we got her back to bed, put in an IV, and gave her 1500 mL of LR (a fluid with electrolytes & sugar). That perked her up for sure. By then, her husband was back from the hospital - it had been too much for him to handle, and he didn't really understand why it all happened or what it meant. But we packed them up and sent them back to the hospital because mom wanted to see her daughter, of course.

When we visited them in the hospital a few days later, they were still exhausted and a wreck. But mom was pumping a good quantity of milk, and they knew that their daughter was on the mend. There were questions and tears, so after talking with them for a while, we left when his family showed up, after arriving from another city. We'll keep in touch to see how things progress. Ugh.

It seems that we transferred care at just the right time. The baby girl just didn't look sick . . . and then she did. It was scary, but taught me a lot.

The second birth was a few days later. This was a second time mom, who had her first in a hospital with an epidural. I was called at 4 AM, arrived at the BC at 4:40 and the baby was born at 5:40. Mom was in the tub when I arrived, breathing through contractions. As they got more intense, she started saying "frick," and then "I can't do this anymore," then "I don't want to do this anymore," and then finally, "F@CK!" Of course, in my head, these are all good things, since transition (the end of labor, before pushing starts) is the hardest part. At the same time it is sad to watch, since I know how miserable it must be. For a second time mom who had an epidural first, it might even be harder, since usually the second time goes faster, is more intense, and you have no real comparison. Her husband was a terrific coach, staying with her and talking her through each contraction. When the midwife examined her, the cervix was mostly dilated, except for a thick and tough layer in the front. She suggested that she stand up, climb out of the tub and do a little dancing or walking. The mom stood up, stepped out of the tub, and hung on her husband through two contractions. (I thought she might pull him over!) Then we got her over to the birthing stool, where as soon as she sat down, the top of her baby's head was visible at the perineum - crowning, basically.

She had a nice slow & controlled delivery of her baby, with no tears. She was thrilled!

The baby came out with a cord wrapped tightly around his neck. He was pretty pale and floppy. Not my favorite. His heartrate & respiratory rate were okay, and with lots of stimulation, he started to breathe and cry. But we kept a close eye on him for a while. His color improved, but wasn't great. After a while, we took him from mom and gave him some oxygen. It helped a little, but then his color worsened again, so we tried again. With the second try, and about 10 puffs of air, he pinked up really well and stayed that way. Thankfully!

Throughout, I kept thinking in my head, "I do not want another bad baby! . . I do not want another hospital transport! . . Not again!" and things like that. I was glad to see him breastfeed very well three times before we sent them home.

The mom was THRILLED with her birth and pleasantly surprised at how great she felt afterwards. After we got her up to pee, she stayed up for a while, she was feeling so good. I love that!

So those were the week's highlights. Hope you enjoyed. I learned a ton!!!

What a week!

On Friday, I found out that I did not get the job I mentioned earlier - the one that pays well and is in a group practice with OBs and CNMs. I didn't think they'd offer it to me, and I was pretty sure I wouldn't take it even if they did! So that made for an easy decision.

I have no idea what I did on Saturday. Oh yeah, I went to the opening Farmer's market in my new town. Great stuff!

On Sunday, I got offered another job. This one is in a place that I would probably consider top choice, but it is only a part time position. Flattering, nevertheless. Then I helped groom the horses. Fun!

On Monday, I helped put in an IUD. More on that later. I also did a well-woman exam, including a physical, a pelvic exam, complete with PAP, and fitted her for a diaphragm. She had complained of rectal itching during the interview, but I forgot to look at her rectum for hemorrhoids. Darn it!

On Tuesday, I called one of my job offers, and told them that I wasn't ready to make a decision, and that their offer was probably not going to provide me the lifestyle to which I have become accustomed. (ha ha! - no really, it wasn't going to let me pay my bills, including at least $60K in loans!!!)

On Wednesday, my client who had her baby last week came in with a persistent headache. Not good. Her blood pressures had been up during labor, and day 1 and 2 postpartum. Now that she was day 8 postpartum, I was worried that she'd developed pre-eclampsia. Postpartum, you ask? Yes, it can happen. Remember, we don't really understand the disease, and despite the fact that we often say that it is "cured" with the birth of the baby (really the placenta), that isn't always true. We made a game plan to care for her if that was in fact the case - really that means to refer her to an OB - but when she arrived, her BP was back down to her normal range (110s over 60s) which was very reassuring, and she had no other symptoms of pre-E. Phew! For me, this was a great opportunity to use my skills of deduction and memory. What do you do to figure out if someone might have pre-E? I had to go through my list and get the information from her - some subjective (do you see bright spots in your vision? are you having any upper abdominal pain?) and some objective (is there protein in her urine?). It was a moment of realization that I've learned a bit - actually a ton - and can put it to use.

On Thursday, my IUD client returned, complaining of abdominal pain, tenderness, and cramping. She also said that she couldn't feel her IUD strings. Again, we prepared, this time for a perforated IUD. Where would we send her? First to the ultrasound or first to the OB? Should we do some testing first? When she arrived, we looked at her cervix. Yay - strings there, looking just as long as they did on Monday. Then we felt her uterus, from the outside and the inside. It felt huge! Like 16 weeks pregnant huge. She'd had a negative pregnancy test. We did an in-office ultrasound, which confirmed large uterus, no pregnancy, but we couldn't see the IUD. Is that because our ultrasound isn't strong enough? Because the IUD has migrated? Wish we knew. I also did a urine culture, a gonorrhea and chlamydia test, and a wet mount. I have to wait for the first two, as they go to the lab, but on the third, I could see lots of PMNs, a type of white blood cell, which indicates likely infection. After a consultation call to a local OB, we put her on an antibiotic for 10 days, and will plan to see her back next week. Again, I felt great about my management of her case. And worried about her!

On Friday, I called both of the women mentioned above, and they reported that they are feeling much better. Then I got called into a birth during second stage. She was laying flat on her back with her knees up by her chest. Isn't this the position we use in the hospital? Isn't the whole point of having an out-of-hospital birth to NOT be in this position? Oh well. Apparently, the midwife in charge had tried to offer a different position . . . to no avail. After watching for a while, and listening to the baby's heart rate go down after contractions (recovering quickly, I might add) and remembering that she'd been having unexplained bleeding throughout labor, I got a little nervous with the lack of progress. I suggested a different position, since that position just isn't very effective usually, and clearly was not being effective at this time. She tried hands & knees for a few pushes, and then the bleeding started again. A lot of bleeding. We got her to the birth chair, and I encouraged her to really get this baby out. She did, on the next contraction. What a momma! Her bleeding continued . . . but the baby came out crying. Good boy! It's nice to only have to worry about one of them! Pitocin given IM, and delivery of the placenta about 15 min later slowed her bleeding to almost nothing. Yay! Beautiful baby boy, 9#!

Saturday, I got a call at 0755 to head in to the birth center. Then about 0820, she told me to wait to come until we were sure this was really going to happen. Her cervix was posterior, long, thick, and closed. The baby was still floating above the pelvis. Oh well. I stayed home, had some coffee, and worked on a paper on GBS prophylaxis during labor. As it turns out, she was having crazy contractions that eventually started making change, but she took herself to the hospital for an epidural. She's 6 cm now & sleeping. The doc ruptured her membranes, and they got thick meconium. Her labor has slowed down a bit. Hopefully she'll have the VBAC she wants. Last time she only dilated to 4 cm, so she's done better this time! Best of luck to her.

Anyway, It's been an exciting week. I'm feeling oh so much more confident, like I know what I'm doing, at least most of the time. The funny thing for me is that here at the Birth Center, I am definitely the most MEDICAL of the bunch, and therefore sometimes the most conservative. I was the most nervous when that momma was bleeding and her baby was having decels. I was first to suggest antibiotics for the infection. I am first to suggest hormome methods of birth control. Why is this funny? Because until now, I've always been the most NON-MEDICAL of the group, whether it be in SNM cohort or at the other practices where I've trained. I'm usually the one opting for low or no intervention, and second-guessing myself when I choose them. I'm the one who defends the momma with the birth plan, when everyone else poo-poos it. It's great to be on the other end this time - I think it will balance me out, and I also think I am offering the folks here some new information and a new way to think about caring for our clients.

Sitting on our hands

I'm not quite recovered from the first birth I attended here at the Birth Center where I'm doing my last bit of training before I graduate. On Monday, a woman came in, laboring well. She'd been having contractions over the weekend, and when examined, was about 6 cm dilated, with a mostly effaced cervix. This was her first pregnancy, and those births often take a long time, but she was already 6 cm when she arrived, so we were all hopeful.

This woman was incredible. She was young - 24 years old, strong and confident. She was willing to try or do anything we suggested to help her labor along. That proved to be important in this story. She was not at the birth center for long, before she was moaning well - in a way that makes us smile because it sounds like discomfort that actually makes a cervix change - and we were pleased. We settled in for the night. She continued to labor well, with her husband and doula at her side. Her baby seemed well, also, with a heart rate that reassured us every time we listened.

Being at a birth center, we don't check the cervix too often - we try to do it only if and when we feel it is necessary, or when the client asks. Often the woman's reactions to her contractions tell us a lot. But after hours had passed, it seemed prudent to check her again, and her cervix hadn't changed much, except that it had changed position, possibly due to a change in the baby's head. No big deal. But when another chunk of hours had passed again, and her cervix still wasn't much different, or maybe even less open than it had been before, we started to wonder what was going on or how we could help her continue to progress. She seemed to labor well in the tub, in the dark bathroom, and when she was left alone. We tried all of that. She seemed to have more cervix on the left side, so we had her try positions that would help the baby's head push on the left side to help it open more. We suggested walking the stairs, doing lunges, going for a car ride, laying down to rest. We offered to break her bag of waters, we offered to give her some meds to help her sleep. She tried everything we suggested (except the meds), although breaking her water took her a while to feel okay about. Finally, sometime around 24 hours after she had arrived at the birth center, her cervix was 9 cm dilated! Progress! A couple of the midwives did some relaxation work with her, using the rebozo, and also used it to help move the baby into the best position possible, with the back on the mom's left side. That must have been uncomfortable for her, but she did it with grace, and was willing to do more. At the end, while the rest of us ate a dinner of pizza & calzones, she went in to the birth room alone to labor on her left side - a position she hated, but knew would help move things along.

Throughout all of this, this woman never complained, ate, drank, peed regularly, and kept her sense of humor. She was amazing.

Around 10 PM, her cervix was completely dilated, except for an anterior lip. One of the midwives held her cervix aside while she pushed, attempting to get that lip around the baby's head. As it turned out, getting her into a hands & knees position while doing that worked well - it was easier for the midwife, and allowed the baby's head to use gravity for assistance as well. At last, pushing commenced! She pushed well for about 2 1/2 hours, in hands and knees, on her side in bed, and for a long while on the birth stool, with her husband sitting behind her.

With a slow, deliberate effort, she delivered an 8 lb 9 oz healthy baby girl just after 1 AM Wednesday morning. Her perineum was intact, a midwife's way of saying that she had no tears! And she was absolutely thrilled with the experience - she did itHer baby was breastfeeding well within 35 min of the birth, and other than feeling weak and tired (like we all did!), she looked no worse for wear. Her mom and in-laws came to the birth center around 3 AM to meet their granddaughter, and help them get home.

The report today is that she's doing well. We'll do a home visit tomorrow to check in. What a happy ending.

The sad thing is that if she'd been in a hospital, she would have had a cesarean due to "failure to progress." Sometimes women just need time to let their bodies do it. And we need to remember that sitting on our hands and doing "nothing" can be best. Doing nothing is really hard- and truthfully, we were doing something really important: believing in the process, in her body, and making sure that she and her baby were okay.

I'm exhausted. And thrilled. I teared up several times today just thinking and processing the experience. It was peaceful and joyful and exhausting for all of us. I'm honored that I got to play a part in helping this woman bring her daughter into the world in such a lovely way.

birth #25

My most recent birth was with a 20 year old first time mom. She was laboring well, got her epidural, and continued to labor rather quickly. During 2nd stage (pushing), she really hated the intense pressure in her pelvis, and had trouble for a while pushing through it. I asked the nurse to get me some sterile water to make a wet compress for perineal support, and then turned around to grab it. The midwife I worked with that night was holding the mom's leg, and said, "Quick! Turn around!" As I did, the head popped out. Oh well - so much for perineal support, right?

The rest of the birth was rather quick, despite my directions to move the baby out slowly . . . she had some tearing - great practice for me, sad for her. Overall, it was a fun one, though, with a great team of nurses & staff.

So much to tell . . .

After pondering, I think I'll just write quick notes here, rather than detailed stories, since it's been over a month since I last posted.

In no particular order:

I had a job interview in another state. They flew me out, paid for my car rental, and arranged a 12 hour day of interviews! Breakfast with the midwives, meet with administrators, lunch with docs and NPs, more meetings with administrators, a tour of 2 clinics, and then dinner with docs, midwives, and NPs. They never really interviewed me. Interesting, huh? They also never really gave me the chance to interview them, so I asked for a follow up meeting the next day with one of the midwives to get my questions answered. Here's what I learned: Everyone's philosophy there seems to be different. This is quite challenging when sharing patients! One of the docs doesn't like women to get out of bed AT ALL during labor. YIKES! I also learned that it is a loan repayment site. What this means is that they pay off my student loans in a matter of 3-4 years. I really liked the location of this job. Friends nearby, lots of places to go play outside. But it would be a tough job to be the new kid, especially straight out of school.

I finished up my training at the hospital where I worked for 6 months. It was sad to go - I learned so much and became friends with quite a few folks. Good people there, even those whose politics were very different from mine. And I think I'll be lifelong friends with one or two of the midwives I met there. Wonderful women!

I moved to another state for my last quarter of midwifery school: Integration. Today was my first day. It was awkward and awesome, like many first days anywhere. I'm working at a birth center that does only out of hospital births - about 70% at the center, and the other 30% at homes. More on that later.

I'm living on a horse farm for the next 2 months. There are 6 horses, 6 hens, 1 rooster, 2 cats, and 3 dogs (Rhodesian Ridgeback from Africa, Australian Shephard, and an English Mastiff). I've always wanted to live on a farm . . My commute is kinda long, but I think it will be worth it.

This post is dedicated to eco.