Doing the Next Best Thing in Action!

Okay I am going to share a birth story of sorts… with anonymity but with permission from the mom.. but with a time line of sorts to show you how a first time mom’s labor went recently… but first let me tell you a few things…

She chose to birth at North Fulton with ISIS midwives.(She drove from Norcross there)
She chose to take Hypnobirthing as her only formal childbirth education.
She chose a doula from our group, although her doula was called out of town on an emergency and she got a back up doula from our group instead. (A rare situation)

Her water broke on it’s own just after midnight on Wednesday morning. She had had an exam on Friday and was 3 cm dilated. Within 30 minutes she was mildly contracting 10 minutes apart. By 2 am they were coming every five minutes but again were still very manageable and mild.

By 5 am although they had slowed some of the time in between but the contractions were now beginning to hurt and had sped up. She was ready to be heading to the hospital soon.

Upon arrival the first exam at the hospital, now 6:30 am, by the midwife Kay showed her cervix had no real change from her appointment earlier in the week and the baby was high at -2 station. She is kept in the observation room after the monitoring strip is completed- she is out to walk about with her doula. The contractions are five minutes apart and she is having to work during each one.

At 9:30 am she is 5 centimeters dilated and the cervix is 80% thinned out although still posterior. She is moved to a labor room- the one with the nice birthing tub.

She had decided to use techniques outside the tub and wait to get in the tub since the baby was posterior and has been from the start of labor. Her doula uses open pelvis positioning, sitting on the birth ball doing figure 8’s and moving her hips. The mom is coping well. Although the doula keeps trying to get her in open knee positions and on her hands and knees, this is only tolerated for short stints as the mom did not like that position. She would tolerate it for no more than 10-15 minutes at a time.

The doula and the dad offered counter pressure and the next check showed she was dilated to 5-6 cm. It was now 1pm. (She has been at the hospital for 7 hours and laboring for more than 12 hours.) She decided to try the tub; she had thought she wanted to try for a water birth, but being in the tub totally did not work. She wanted to stand and have counter pressure more than she wanted the water. So she practically crawled over the side of the tub to get out. The mom was feeling very discouraged since she had not made any significant change in 3 1/2hours. (This is where most facilities in our area would have suggested Pitocin if not earlier. This is where some would have suggested an epidural to help the mom relax.)

Margaret, the next midwife arrived and checked her at 3pm and now the mom was 6-7 centimeters and almost fully effaced. She suggested the mom get in the exaggerated Sims position and concentrate on her hypnobirthing CD. The mom laid down and quieted after receiving a dose of Fetanyl(a short acting narcotic given by IV). She began to relax in between her contractions but still benefited from getting counter pressure applied to her back.

By 6pm she was feeling pressure in her bottom and declared that she was done! The exam showed she was now 7-8 centimeters but totally tight and tense. She had been inquiring about speaking to an anesthesiologist since she had not done any research on epidurals and had no real knowledge of them but thought she wanted to consider one. Margaret agreed that an epidural may really prove to be effective since the mom could no longer relax and getting this baby to turn would mean we needed to have her be relaxed. So after a second dose of Fetanyl, an anesthesiologist was called. This mom has a strong case of scoliosis. This makes inserting an epidural catheter quite difficult. And after 4 attempts although not a good placement, the mom did not feel like she had good relief. Soon after this Pitocin was added.

After attempting several boluses of medication it was decided to attempt a new placement of the epidural at 10:30 pm. This one worked great and gave the mom full relief. (Some moms do not get full relief from an epidural, but this was thought to be more due to the curvature in her spine)

By 3am an exam showed she was fully dilated and the baby had moved down to 0 station! Since she had an epidural on board and needed more rest, it was decided to have her only grunt when she felt the pressure and she did not actively begin to push until 4am. (Some facilities would have had her actively pushing as soon as she was completely dilated- others would have followed this plan to let her “labor the baby down”.)

Again beginning to feel more unwanted pain, she received another bolus of epidural medication at 6am. The posterior baby was down to +1 station but they were attempting to get him to turn by putting his mom in the exaggerated Sims position again. (Most facilities would have suggested a cesarean at this point if not earlier. The would have sited that she had been completely dilated for three hours.)

By 9:30 am the baby was down to +2 station but was not budging any further over the next hour. Margaret called Dr. Frederick at 10:30 pm, her back up physician. Although the baby and the mom were both doing fine, she must have thought that they needed instrumental help at this point. He was in the room within 15 minutes. A decision was made to assist the mom’s pushing with the use of the vacuum. Margaret felt all the mom needed was to turn the baby a bit to get it to come on out. She shared her feelings with both the doctor and the parents. Her years of experience were providing her with confidence. After two attempts, and the baby making quite a bit of progress but not quite enough, he reluctantly said he would try the forceps once before heading into the OR.

At 11:05 am the baby boy was born. He was not a huge baby- only weighing in a just under 8 pounds 5 ounces. (As a doula I have seen vaginal births of babies who weighed in excess of 12 pounds!)(One of the midwives in this group- not any of the attending ones, had projected the birth weight a week earlier as already being over 9 pounds! Just goes to show you can’t predict the future!)

So think about this… if she had had Pitocin earlier perhaps it would have caused the baby to born sooner.. or perhaps it could have caused the baby to be stressed… or perhaps it could have caused the baby to be jammed down in that posterior position insuring he would not fit and insuring a cesarean birth…who knows? What if she had gotten an epidural earlier? Could this have caused the pelvis to relax and perhaps get the baby to turn sooner? Or would she have had Pitocin needed earlier and her contractions may not have continued well without the use of Pitocin?

What would have happened if the staff at the hospital had not been on board with this mom’s desires? Having a nurse enter the room and undermine her confidence or choices is the last thing this mom needed. (At some hospitals their natural rate is so low the staff does not feel prepared to support a mom in going without medication. This causes some to seem like epidural pushers.)

What would her labor have been like if she had not had a midwife who believed and trusted in the process? What would have happened if they did not have a doula who was there encouraging (to give courage) them to keep trying? They must certainly have had a cesarean birth if they were held to a clock and the standards used in most hospitals. After all she had broken water for 17 hours. (Although this is totally acceptable- it is rare today to have moms outside of this facility and a few choice others go this long without a lot more intervention.) She would have certainly had a cesarean birth if the standard use of 2-3 hours of pushing had been used to determine that she could not push her baby out. She had been fully dilated for 7 hours before the birth!

It is about having all the pieces of the puzzle: location- birth team- educating yourself- and doing the next best thing along the journey. This mom may not have had the hypnobirthing, non interventive birth she desired. But she had a vaginal birth of a baby with APGARs of 8 and then 9- born screaming to show his delight in finally getting out! Having only one of those elements may not have ended up with the same outcome. A doula without the supportive staff is not fully equiped to help you get the birth you desire or if the care provider is not on board. So, it is a full team effort.

The mom said she felt having the doula kept her drug free for over 24 hours of her 36 hours of back labor. The doula was the one constant throughout her labor- never changing shifts or going off call during the whole labor. She stated that the way that the doula worked with her kept her from being exhausted earlier in labor. She said she would tell other pregnant moms that her flexible birth plan helped. It had been a long and painful journey, but she did it! She did not realize that at the time of labor- in that moment, it is hard to make decisions. She never knew how overwhelmed and delirious she would feel when having to make decisions. She said she now really understood the importance of having a great support team that she trusted as they sometimes had to help lead her through tough moments and decisions she otherwise would have felt unequiped to handle. The had remained calm.

I asked her about her choice for classes; hypnobirthing. She said she feels it would have worked without 36 hours of back labor! In the classes they are dismissive of the “what ifs” due to not allowing that negative thought to enter into your mind. So since they were dismissive of back labor- of a baby not being positioned properly, she would not have known what to do if she had not had a doula to help her. She had listened to the tapes over and over in practicing. She had visualized her baby being positioned perfectly. She had felt relaxed when she practiced the techniques. She said she may have chosen a different class if she had not had a doula, but felt the doula would be there in case of the “what ifs”.

I will say I think hypnosis for birthing is a good tool- but it is one tool. I think just because you prepare yourself with other tools- more knowledge about the “what ifs”- it does not set you up for those negative things happening- it just makes you more informed and prepared. I teach some hypnosis for birthing ideas and sell some products that support this practice- but I personally do not see it as an end all for most labors. I think a woman needs to have her “tool box” full of tools.

Her doula shared that when we usually discuss the “what ifs” in discussing birth options, she has sometimes found it hard to work with these moms because their fear of talking about the “what ifs” cause them to be unprepared for them if they do arise. Talking about how to deal with them when they are happening is hard for everyone.

This mom told me she knows she missed having a surgical birth by the hair on her chiny chin chin! I think she is right. She had set herself up with the right team and many of the right choices for her birth to have the outcome she most wanted- a healthy baby- and a healthy mom without a surgical incision on her abdomen to get them both!