reflecting, remembering back

Now that I've been a midwife for about a year, I'm precepting students, both student nurse-midwives, and professional midwifery students. In preparing some things for them, I came across this delivery note from one of my early births. It's fun to read, and then realize how far I've come in merely 2 years. The other fun thing is that 7/7/11 is the date I got certified/passed my boards. This was exactly one year to the day before that. Fun! 7/7/10

Delivery note: G2P1001 at 39 weeks 4 days. T labored well, changing positions often, first on her bed, then upright, then into the tub at approximately 0900. Active phase of labor was approximately 4.5 hours. SROM occurred at 0930, with leading membranes. Mom pushed gently and spontaneously, allowing for a very controlled, gentle descent and time for perineal stretching. The small room was nice & warm due to the “first day of summer.” Throughout, FHTs were stable, ranging in 120s to 140s, with accelerations over 150 heard during contractions on several occasions. After a 23 minute second stage, the head was delivered at 0952, followed by spontaneous rotation to LOP. Mom raised her hips above the water, no nuchal cord, delivered the anterior shoulder with mild traction and then the posterior shoulder and body. A viable female neonate was placed immediately on the mother’s abdomen where she was noted to be centrally pink with spontaneous cry. Care was taken to keep infant’s head above the water line. Apgars 9 & 9. Weight 7# 14 oz, 21 inches long. Placenta delivered Schultz at 1002 with third contraction after NSVD with mom standing, mild traction. Appears complete with three vessel cord. Mom then got out of the tub, and laid down for 3rd stage management. Hemostasis was easily achieved with fundal massage. Blood loss approximated at 300 mL. A first degree laceration of the right labia was repaired with 2 interrupted stitches using 3.0 vicryl and 1% lidocaine. Bilateral, periurethral tears were also noted, but required no repair. Baby was back in mom’s arms at 1015, and began breastfeeding almost immediately. RR=72, HR = 132, T=99.1 (axillary) Mom was stable postpartum, with BP=127/65, T=99.2. Big sister and grandparents met the new baby at 1020. At 1030, Mom walked to bathroom, voided, and then got into her bed. 600 mg ibuprofen and ice bag put on perineum taken at 1045 after reports of discomfort. Baby breastfed on both sides, and then fell asleep. Newborn exam completed at noon with no abnormal findings. Postpartum teaching done, including danger signs, when to call CNM. Family fed and resting when we departed at 1230.

Here is the journal entry I made (for school) regarding this birth:
 • I caught a baby all by myself. It was a lovely homebirth, with a waterbirth. Sally just stood there and let me catch. It was awesome. The whole experience was quite lovely, with a nice labor that I felt good supporting, managing. I had just met the couple in an AP visit two days before, and it was good to know the concerns the Dad had about the homebirth so that I could be sure to address them during the actual labor. Checking in with him during and after the labor, it seems that he felt good about the experience.
 • I delivered the placenta well – impressed Sally because I followed the curve of carus even though our client was standing up!
• I did at least one suture all by myself. :-) And there were only 2.
• Did another newborn exam. Still feeling somewhat awkward about the routine.

TOLAC & successful VBAC

TOLAC= TRIAL OF LABOR AFTER CESAREAN SECTION VBAC= VAGINAL BIRTH AFTER CESAREAN This week, I was honored to be part of an amazing, life-changing experience for several folks: the mom who succeeded in her TOLAC, and my student, who got to experience the thrill of that moment (and catch her 2nd baby). J felt that her first birth experience was incomplete - she had been pregnant, and then laboring, but then had a cesarean due to concerns about bleeding and some concerning fetal heart tones . . . friends thought she was crazy to choose a birth center for this birth, but J felt safe and well-supported by her midwives (me!). J came into the birth center early in the morning about 7 cm dilated, and got "stuck" there for much of the day. This was frustrating to her, but not to us . . . as out-of-hospital midwives, we have the luxury of patience . . .and don't jump to using pitocin as they do in the hospital (we only use pitocin for postpartum hemorrhage, since it is a dangerous drug for babies-still-in-the-womb). J's mother & sister were there, exuding energy that was lovely but not so conducive to laboring (aka, Sphincter Law, see below). So J labored all day with her husband and her doula. It was obvious to me that she was not suffering, so we supported her emotionally through her frustration and occasional "breakdowns," when she cried . . .she also stated a few times that she imagined having her baby at night, and it was a bright sunny mid-summer day! We sent J's family & doula home after a while, to see if the pressure of being "watched or "on-stage" changed her labor pattern or progress. Once evening came, things got more serious, and once it got dark, she started to feel "pushy." Laws in this state require that TOLAC clients have a 2 hour or less second stage (the pushing phase of labor), so I gave J a pep talk about pushing. Typically, I just let women figure it out for a while before I coach them. I think it is intuitive to push, and in most cases becomes spontaneous, but in this case, I wanted her to be sure to be effective and efficient. J got serious, and pushed out her baby in 47 minutes. She was sitting on the birth stool when she delivered. The head delivered, and the baby turned to look at me, with her eyes opened, and then started to breathe and whimper. I nudged the shoulders to deliver, and my student got to truly catch a baby (gravity makes the catch much more important than when someone is laying down), and then handed it off to me. J looked down at her baby, between her legs, and said, "It's a girl!" Baby girl was pink and gorgeous, breathing easily, looking up at her momma. J's mom said, "reach down and pick up your baby!" but J responded with, "I just need to look at her!" Then she said, "IT WAS SO WORTH IT!!!" J had a LONG labor. More than 24 hours at home before coming to the birth center, and then another 16 hours there. And at the moment of the birth (well, at least within the first minute), she was exclaiming the thrill of accomplishment! That brought tears to our eyes - all of us, I think. J reached down and picked up her secretly-wanted daughter. We cut the cord (the placenta had delivered spontaneously after 3 minutes, plopping down into the bowl under her), and moved J and her daughter to the bed to relax, get to know one another, and start breastfeeding. It was beautiful and moving and lovely. Baby girl turned out to be a healthy 8.5 lbs. In rehashing the birth, J wanted to know details that she didn't remember, and she's still trying to figure out why she got stuck. I call it emotional dystocia tied up with performance anxiety, complicated by her desire to deliver a baby in the dark. In the end, it all worked out. They were struggling for a name, and had several options to decide on. Once at home, they were rolling names around, and came up with one that fit. It means, "born at night." Beautiful! It is an honor to be at any birth, but there is something powerful and special about a successful VBAC, especially an unmedicated one. Women are immersed in the experience, and their accomplishment is so meaningful to them. I just love it! NOTE: Sphincter Law - Ina May Gaskin coined this term, and this is my understanding of what it means. The cervix is a sphincter, just like the urethral opening (where we pee from) and the anal sphincter. When we urinate or defecate, we typically prefer to do so privately, and any interruption can slow the process by closing the sphincter. Ina May (and I) believes that the cervical sphincter also operates this way. Women who feel safe and protected in their birth experience labor more effectively. Women who feel violated, unsafe, watched, surprised, etc. often have slower or stalled labors. In the story above, J was worried that her labor was "taking too long." She had a mom, sister, doula, husband and two midwives "watching her." During one vaginal exam, I actually felt her cervix start to close around my fingers (so I pulled them out right away!)! Once we reassured her that stalling was normal, we were patient, and sent her observers away, her sphincter relaxed, and her labor progressed. Go, Sphincter Law! Go!

a day in the life . . .

I really felt like a CNM this week. Here is a quick run-down of the end of my week (the early part was marred by a killer head cold!)

Thursday, I had prenatal clients in clinic. Saw one of my favorite ladies who has finally made it to 37 weeks for the first time (this is her 4th baby, and we cannot do homebirth before 37 weeks by law). Met a couple for their first visit. Saw repeat clients who are getting close to term, and excited about meeting their babies soon.

Friday, I did well-woman all day, and that consisted of: 3 paps, pulled out an IUD, put in an IUD, checked IUD strings, counseled about birth control, hormonal changes, nutrition, exercise, weight loss, tried desperately to diagnose lesions on a client's face, did 5 physicals, and more. I cleaned the room myself between clients, took their money, billed their insurance companies, and mostly stayed on time. (I would have been more on time if my clients had: a. remembered to bring their registration paperwork that they were sent; and b. if they had been on time!)

Saturday, I met with a client who was post-dates (getting close to 42 weeks - we also cannot deliver AFTER 42 weeks outside the hospital, also by law). Using my midwifery skills, I induced her labor naturally. It took a few hours, and she got walks and acupuncture between my exams, but it worked! She was in active labor by 8:30 pm, and had her baby in the wee hours this morning. A lovely birth, and a surprise little girl! (some of my clients opt NOT to find out!) As we said goodbye, the mom gave me a good hug, a real hug - you know, the kind where you can feel gratitude in their whole body? Left me feeling great.

Feeling more in the groove these days. Enjoying my clients, my work, feeling like I'm using my brain, my skills, and gaining expertise and awareness each and every day

So, this was a good week. I hadn't had a birth in a few weeks, so was a little sad about that. It has become a joke at work that when I'm on call, no-one goes into labor.

I'm still on call . . . heading to bed now. Hoping that little pager will chime to wake me up so I can be there to welcome another little one to the breathing world.

December

One birth in December that I was a part of from start to finish. That's all. And is just happened the other day.

It was a really great birth in retrospect. Healthy baby, healthy mommy, mommy very proud of her hard work, new papa pleased with the situation, etc. However in the moment, there were some challenges!

First, there was the grandmother of this new person. She was VERY nervous about this whole out-of-hospital thing. When I met her, she said something like, "She's really sick" in regards to her daughter puking her guts out. As a midwife who has attended 45 previous births in a midwife role and over 20 before that as a doula, I responded with, "This is really normal during labor," as I know it is. Not fun, but most bodily fluids make an appearance in most births. Wow, I got a look that would have killed. Nice to meet you, too, Grandma.

I KNOW she was really nervous, and I give her credit for being as supportive as she was throughout the labor, and afterwards, she did tell me, "You ladies are amazing." But some of her other lines included:

"No-one pushes this long!" After 90 minutes of pushing for a primip. Normal.

"Honey, maybe you need a doctor!" This was the only one that offended me personally, a little.

"Did she tell you how difficult my first birth was?"

I'm sure there were more. And truthfully, I really would have been happy to talk with her about her concerns, fears, worries - and I did, when I could - OUTSIDE THE BIRTHING ROOM. My biggest concern is that she would get into her daughter's head and ruin her labor. Slow it down. Make her give up. Get her worried . . . and she was already working harder than she'd ever worked in her life.

But the real point here is that most of us don't get the opportunity to see birth in a natural way. Birth is "supposed" to be in a hospital. It is on TV, right? It's where most of us were born. It's where there are doctors and nurses to come to the rescue at any moment. Especially those anesthesiologists! So most of us cannot fall back on anything familiar when we see a birth for the first time. It can be very stressful when we love the person who is laboring. She is in pain! She is moaning, uncomfortable, miserable, and talking about wanting an epidural or that she can't do it anymore, etc. But I know that all of these things are normal and okay. As long as the baby is okay, and there are no health concerns, I push these momma's to keep going, keep trying, think of only one contraction at a time. And most of these ladies are thrilled after-the-fact with what they have accomplished.

And you know what? There's good research that these momma's feel more confident as new mothers. Awesome, right?

So in the end, this grandmother learned something amazing, and she'll probably process it and remember it for her whole life. Hopefully, she'll tell her friends about it too, so that it doesn't seem quite as strange or crazy as they might think. Maybe.