Saturday, April 17, 2010

From Nurse to Gentle Birth Advocate, Part One, J.'s Birth Story

I feel like I am kind of going backwards here, but since I didn't discuss J.'s birth in detail in the story of his first year of life, I'm going to talk about his birth before I move on to other topics and experiences. I believe that how we birth has a strong influence on infant development, and it is something we need to be mindful of so we can make informed choices in our care.

I would say that I went into my first pregnancy with my expectations for birth colored by past experiences. I had supported a friend during labor and was present at the birth of her daughter. I witnessed several births when I was in nursing school. I heard the stories of other women's births. I had a realistic idea of what a hospital birth entailed, and I didn't see anything wrong with that. I wanted to have an unmedicated birth, but didn't really feel too strongly about it. I was just willing to wait and see how things went. I knew I didn't want a c section, but didn't know much about how commonly used interventions increased the risk of having a surgical birth.

I thought I knew pretty much what I needed to know. I had studied maternal/newborn nursing, I was aware of what the hospital routines were like. I signed up for a childbirth class, mainly so my husband would have some idea of what to expect. The hospital where I was to deliver was about 30 minutes away so I ended up taking the class at a closer hospital, just for convenience sake. It didn't really occur to me that there are different types of childbirth classes, so I didn't do much shopping around.

I did ask my OB a list of questions about his practice style, including c section rates and episiotomy rates, whether he used forceps or vacuum, and how frequently, that sort of thing. I had spent some time working in a newborn special care nursery, and had heard some horror stories about the use of vacuum and forceps, so I really wanted to avoid them. My OB said he did not use vacuum, but just the forceps and he wouldn't do anything that he wouldn't do for his own child. I was satisfied with that answer. I wrote a birth plan and went over it with my OB in the third trimester, he was agreeable to it and included the birth plan in my chart.

As I was nearing the end of my pregnancy, an ultrasound was scheduled. I don't recall the exact indication for the ultrasound, but it sounded pretty routine. The scan was done at 37 weeks and 4 days gestation. The baby's weight was estimated at 8 pounds, 2 ounces. I don't recall anyone mentioning that ultrasound estimates of weight could be off by up to a pound, so I was quite content to let the OB schedule an induction. I was getting very uncomfortable. It felt like that baby's foot was a knife sticking directly into my liver. From what I had heard, 37 weeks was considered full term. I thought, why not get him out while he still fit, right? I was actually rather annoyed that they wouldn't schedule it until he was close to 39 weeks. Not that they didn't do that, but his due date was toward the end of the week and inductions were normally scheduled at the beginning of the week. However, inducing for a suspected large baby does not decrease the risk of c section, nor does it decrease the risk of complications like shoulder dystocia. I never received any information on the risks and benefits of inducing from my obstetrician. I did get a heads up from my pediatrician, but unfortunately I didn't heed his warning.

Now, I had heard enough horror stories about pitocin inductions that I really wanted to avoid one if possible. So after discussing this with my OB, he suggested using cervidil to ripen my cervix. I didn't happen to have heard any cervidil horror stories. I was scheduled to come to the hospital on Tuesday April 9th, at 38 weeks 5 days. News flash! There are cervidil horror stories. This is one of them.

When I arrived at the hospital and got through the admitting process, the nurse put on the belts to measure contractions and the baby's heartbeat. To my surprise, she said that I was contracting at regular intervals. The only thing is, I didn't feel the contractions at all, so I didn't think they were particularly significant. I can't recall the details very well, but I believe I was about 1 cm dilated. The nurse inserted the cervidil, which looked like a little piece of gauze with a string attached. This allowed it to be removed if it caused contractions that were too strong. It didn't really do anything. I spent the day at the hospital and used some natural methods that the nurse suggested to try and get labor going. I walked up and down the halls and bounced on a birthing ball until I was sore and aching all over, but I did not go into labor. At the end of the day, they sent me home, but with the plan for me to return the next morning.

I didn't sleep that night, excited and wondering when I would go into labor and have my son. When I came back the next morning, still not in labor, they repeated the cervidil and after monitoring for a short time, sent me home with instructions . I was supposed to remove it if contractions became too strong. Late that afternoon I started having contractions that were uncomfortable, though not painful at first. They were regular. I decided to keep busy, running a few loads of laundry and making some dinner for my husband and myself. By the time I had the food ready, the contractions were strong enough that I wasn't enthused about the idea of eating. I started to time them around 7pm and they were 2 minutes apart for 1 hour. I called the doctor and received a call back from the OB on call. I asked if I should take out the cervidil because the contractions were so close, but she said no. But she did say to come in.

I arrived at the hospital around 9pm. I was still about 1 cm dilated. The admission was pretty straight forward, but the contractions were really intense so I was a little snappy. I believe there was some bad language involved. My husband commented on that later, but you know, he wasn't the one in labor. There were several painful attempts to get an IV in. I tried walking the halls but the contractions were coming every two minutes and I found it really hard to cope with them. A They were about a minute long so that meant I was contracting 50 percent of the time I was in labor. I learned later that a contraction pattern like this is not typical for early labor, and was almost certainly due to the use of cervidil. I tried getting into the shower but it didn't provide any relief. I thought I was such a wimp for not being able to handle the pain. Around 11 pm the nurse gave me a dose of Stadol in my IV. I felt nice and relaxed, for about a minute until the next contraction hit. After that it did nothing for me.

By 1 am I was about 2cm dilated, which was rather disappointing, and had an epidural placed. I wanted to wait longer but I felt like I couldn't cope with the contractions being so close together. It felt like a bolt of lightning went down my right leg when they put it in, and but it seemed to work. I felt myself jump involuntarily, thank goodness that I wasn't injured! At first one side was better than the other but after rolling onto my side it evened out. The contractions were no longer painful but I had severe heartburn with every single one of them. I tried to chew on ice chips for relief, but it didn't work very well. After the nurse left the room and the lights were turned off, I felt a pop and a warm sensation. I was pretty sure my water had just broken. I used the call button and the nurse came back in. I was correct. She checked the fluid, and got me settled again with dry bedding, then left.

After that, my husband and my only support person went to sleep. I was supposed to try to get some sleep too, but I was wide awake. Who could sleep with fire in their throat every two minutes? The husband was snoring, which irritated me. I threw some ice chips at him and growled at him to stop snoring. This, my friends, is why you hire a doula. Trust me, it's worth it. YOU are worth it. After a while I finally asked for something for the heartburn and was given some medication. At 4 am the nurse checked me, and to her surprise and mine, I was fully dilated. Did I want to push? Sure, I wanted to see the baby, why not? No one suggested that I labor down a little until I felt an urge to push. This mistake would lead to hours of pain and frustration.

There were a few decelerations throughout my labor at various times. I was told to quickly roll onto my left side and I did. I didn't think too much of it at the time, had seen similar scenarios when I was in nursing school. His heart rate did come back up with position change. They may have given me oxygen doing one of the decels, but I don't recall for sure.

Around the time that I was entering the second stage of labor, I started having severe pain very low in my abdomen that I felt through the epidural and which did not stop between contractions. They had been giving IV fluids for hours and I had not been up to use the bathroom. The nurse got 700 cc of urine out of my bladder with a catheter. That took care of the pain for the moment. I'm a little fuzzy on the exact timing, but I did start pushing soon afterward. I would guess that it was sometime around 4:30 to 5am. After about an hour I was in a lot of pain. The contractions hurt. A lot. I asked them accusingly, "What happened to my epidural?" They said it was still going. After 2 hours I said "this isn't working, I want you to use forceps." I wanted that child out, it seriously hurt. It hurt to push and it hurt not to push. They reminded me of my birth plan, that I said I didn't want forceps unless the baby was in distress.

I have to give the doctor credit for something, because he stayed with me from about this point on. Not too many obstetricians will spend more than 2 hours with a woman in the second stage of labor, but he did. He had far more empathy than the nurses or anyone else did. My husband was holding one leg when I pushed, and there was a nurse orienting that was holding the other leg. The only problem was, as soon as a contraction was over and I stopped pushing, they would just let my legs go. I was completely numb so I had to reach out and catch my legs with my hands so that they wouldn't hit the side rail. The doctor noticed this and set up the bed so that I could relax my legs in an elevated position without anyone having to hold them. He told them to help me hold my head up when pushing instead. I know stirrups get a bad rap, but since I was numb from the waist down, the leg supports were actually a huge relief. My neck was soooo tired, and having both neck and leg support for pushing helped tremendously. I didn't feel able to advocate for myself during this stage of labor, it was difficult even to speak. When I needed a sip of water after each push, I gestured toward the cup and made a noise. Why did I feel so helpless? In retrospect, I probably should have had them shut off the epidural and let me get out of the bed to push. I couldn't have imagined it at the time though, it was so painful even with it.

There were some good things that happened in the second stage. The hospital staff were very mindful of my birth plan. I got to see the baby's head with a mirror. I got to touch his head and feel his hair. I was really happy about that. It put me in a better frame of mind and gave me some strength to go on. The doctor that cared for me during the second stage of labor was NOT one of the doctors that has recommended the induction, nor was he involved in the process. My primary doctor went off call at 7 am and his partner came in at the end of this chain of events. In retrospect, I think we were lucky that this happened because he was probably the most supportive of vaginal birth of all the doctors in the group. He certainly had a great deal of patience, and a calm, soft spoken demeanor.

After another hour, the doctor looked at my husband and I and said "I don't think this is going to work." We thought he meant that he would need to do a c section, so when he asked if he could cut an episiotomy, it actually sounded good at that point. I was kind of thinking, if that is all you needed to do, why didn't you suggest that already? So he cut. I think he may have cut mediolateral incisions on both sides, but I'm not sure now. Our son entered the world about 15 minutes later, at 8:45 am.

After J.'s head and shoulders were born, the doctor told me to reach down. I think he realized how hard I had worked for this, and wanted to be sure I got the maximum reward for my efforts. I thought the baby was all the way out, but when I took hold of him under his arms and tried to lift him, I realized that he was only delivered to about his waist! Then he slid out and I lifted him onto my chest. I helped dry him gently with blankets and I talked to him. He looked right into my eyes and he didn't cry at all. My husband was a little worried but I knew the baby was fine. I was blissfully unaware of anything else for a few minutes. I do recall the doctor doing fundal massage and me telling the baby that "the doctor is really hurting me right now." A little mild panic in the room over bleeding and "we would like to give pitocin." Ok. I didn't even notice the birth of the placenta, I never saw it. J. had my complete attention. He was here and he was beautiful!

Of course it was a bit hard to look at him while laying flat on my back. But I didn't really notice that at the time. Wasn't our nurse pretty? She's making me look worse. LOL

I opted to allow the nurse to do his routine newborn care on the warmer while the doctor spent about 20 minutes stitching me up, as the process was rather uncomfortable. I was unaware at this time of the benefits of skin to skin care of the newborn. Interrupting this bonding time immediately after birth effects neurological development, breastfeeding, and the development of gut flora in the newborn. I now wonder how our first hours, days, and weeks and beyond might have been different if J. received uninterrupted skin to skin care in his first hours of life.

J.'s first cries came as he was transferred to the warmer. At the time we believed this was a normal part of newborn care. It never occurred to me that new babies should be cared for differently.

8 pounds, 1.5 ounces.

Dressed with hands covered. Eye ointment blurs vision.

I did feel much better, had a chance to change clothing and now sitting upright so I can see the baby better. J. nursed within an hour of his birth.

J.'s daddy holding him for the first time. My husband looks like someone who has also been up all night. Except for the nice, long nap after my water broke, of course.

It's been a long 8 years since this day. It's hard not to look back and think "What if things had been done differently?" We are sporting a few wrinkles and grey hairs. Can we blame him? ;-) Nah, he's too cute. Let's just blame the doctors. It's more fun.

Happy 8th Birthday, J. We love you!