After writing my last post, a "block" seemed to have been moved; story after story of amazing births I've been privileged to attend just seem to tumble from my memory; I sat down at my computer to start writing about them, and then I thought about E.
E. gave birth to her third child, a precious little girl, several weeks ago. It was E.'s third C-section, her second attempt at VBAC, her third attempt at a vaginal birth. With both of her previous birth experiences, the argument could be (powerfully) made, that mismanagement of her labor led to each C-section. With her third birth, only God knows why events unfolded as they did, and led to a third surgical birth, this one an emergency situation, that occurred with E. under general anesthesia.
E. had tried so hard to "do the right thing". She takes excellent care of herself. She's well educated, seeks out the right support for herself, does everything she can to have a safe, healthy birthing for her children and herself. For her first birth, she chose to be attended by very well-known Certified Professional Midwives; for her second, she chose to attempt VBAC with a physician who works very hard to be "hands off" and encourage her patients to give birth on their own terms; for this third birth, E. was fortunate enough to live in a city in which a prominent (it could be argued the national expert) physician-researcher (responsible for probably the most comprehensive study on VBAC ever published) practices. She chose this physician to attend her for her third pregnancy and birth, and together, this patient/physician team worked very hard to secure a healthy pregnancy and safe birth. In the end, that is exactly what they did...although with a significant "hitch" that both of them would rather not have experienced.
After an uneventful pregnancy and smooth first few hours of labor, no pain meds, no epidural, with an attentive husband and doula at her side, E. had progressed smoothly to nearly transition labor. I was so pleased for her! Having popped my head into her labor room to welcome and encourage her, and a share a quick hug with her doula, a close friend of mine, I picked up my bag and clocked out for the day (she had arrived near the end of my shift, and I would not have the good fortune to be her nurse). There was a celebratory mood in the room, and I was nearly floating on air out of happiness for her.
On my way off the unit, a barrage of nurses, residents, and the prominent attending physician suddenly came barreling out of the nurses station, clamoring towards E.'s labor room. The flurry of activity, calls for help and surgical preparations (anesthesia! OR!) that were occurring made it clear that something had gone wrong. The amazing emergency "machine" of our unit had mobilized. When a true emergency occurs, this is a thing to behold. The nurses, techs, clerks, anesthetists and physicians on the unit truly become a single entity, each individual a cog in a wheel that is rotating furiously, each performing nearly automatically, and almost always expertly, their own function, with the goal of getting the mother into surgery, and keeping her and her baby safe. While I admit that the "adrenaline addict" in me gets a bit of a "high" from situations like this, and while my main goal is to avoid having any of our mothers go to the OR, times like this make me feel grateful, and humbled to be able to call myself a part of this amazing team.
Already out of my scrubs, and off the clock, I felt helpless and powerless as I watched in dismay the "machine" thunder down the hall towards the OR with E., hunched over in "knee-chest" position in her bed, her doula and her husband running behind as they pulled on the white, zip-front "bunny suits", caps and masks they would need to accompany E. in the OR. I knew she would be OK. I knew the baby would survive...because I know that machine; but I ached that she seemed to be losing her last chance to have the vaginal birth she had always dreamed of having.
After the commotion had settled, the baby was out, and both she and her mother were deemed safe, I learned that E. had experienced a uterine rupture! This blew my mind. Why her??? She had worked so hard! She was well nourished, it had been several years since her last birth, plenty of time for good tissue healing, and from her previous op reports, she had had a strong, "double layer" repair after her second C-section. She had labored naturally, without the aid of Pitocin, and had (gratefully, in retrospect), had no pain medication or epidural to mask the symptoms of uterine rupture. She had labored to almost complete dilation. The odds were so in her favor for a vaginal birth that this occurrence was a true stunner.
Fortunately, the tear in E.'s uterine wall was repairable, and with the skill of what I am convinced is the best surgeon and surgical team in the country, E. was safe, her baby is healthy, and I know she will heal well.
Physically, at least.
But emotionally?
E. knows that what happened to her was a random, unlikely occurrence. She is grateful and happy to be alive, and to have a healthy daughter to love and raise; but still she grieves for her lost opportunities to experience birth as she had always expected she would; to give birth the way she was designed to. To give birth the way most mothers take for granted. To feel her baby emerge from her body as she worked and pushed to bring her forth under her own incredible power.
Everything had happened so fast. It must have taken quite a bit for it all to sink in, for E. and her husband. This is a couple that has always wanted a big family. Even as they counted their blessings from this averted tragedy, I heard that E.,s husband had asked their doula if they would ever be able to have more children. "Maybe...but only if you schedule a C-section at 39 weeks", she had replied...and this coming from a woman one of whose main missions in life is to help get our country's C-section rate down from it's current outrageous high of 33 percent. For a while I worried that E. just was not coping with her loss...that she was so focused on having a vaginal birth that she was letting the first precious weeks with her new daughter slip away ruminating about her lost opportunities and planning for a future VBAC. While most would feel that decision would be unsafe (and I even include myself in that number), there are midwives (who's judgement I reject) out there who might accommodate such a request. Indeed, well meaning posters on our local birth-support email lists tried to encourage E. by questioning whether she experienced a "true" rupture (she did) rather than "just a dehiscence", by questioning the decision to perform the surgery (!!??), by questioning her memory of the events, and by encouraging her to look forward to a VBA3C in the future. After a couple of unreturned telephone messages to her, and several emails without response, my worries increased...for a while.
My worries were unfounded. As much as I know she cares, I think right now I'm a reminder to E. of her lost dream of a vaginal birth. I understand that, and I won't pursue contact that she might be uncomfortable with, even though I mean only to support and care. Through the community of women who support birthing women in my city, I've learned that E. is doing well. From time to time I will see a post from her on our local ICAN (International Cesarean Awareness Network) email list, and I can tell that she is working through her grief in her own way. One post in particular that she made, was an impassioned plea to the leaders of ICAN in our community to provide more support for "those of us who will never have a vaginal birth".
My heart goes out to her. She is correct to make such a plea. While I support the work that ICAN does both nationally and locally, I've been concerned for a while that the focus on avoiding C-section, and the focus on VBAC neglects those women who may never experience another pregnancy after their C-section; that those whose C-sections were truly life saving or health-preserving might doubt their caregivers, or more importantly, their acceptance of their care-giver's decision. What aggravated me most in this particular situation, was how quick E.'s "supporters" were to second guess both her trust of her medical team, after she had put so much time and effort in choosing it, and in that team's decision, particularly when those supporters were so far removed from the situation. Hindsight is not always 20/20, and I did not consider that support.
I don't think this is or was intentional; but I think some of the printed materials, and particularly those mothers who were able to achieve a successful VBAC after a truly unnecessary c-section can inadvertently give off the "vibe" that ICAN is only for those mothers who are recovering from, or avoiding abuses of the medical system. Knowing that it will be a fine line to toe, I would like to see the group, while avoiding the risk of "normalizing" the procedure, provide more overt support to mothers who, as E. has so passionately phrased it, will never have a vaginal birth.
C-Sections are Births, too. No one would deny that, but I think in our zeal to reduce the c-section rate, to avoid that first c-section, and to promote VBAC, we have inadvertently minimized that. We in the medical community, in our rush to protect the safety of a mother and baby needing an emergency or emergent c-section, or to keep a busy, even over-loaded maternity unit running efficiently, are guilty of the same. That "machine" I spoke of, the one that I so admire and am so proud to be part of most of the time, continues to, on a calmer level, run much the same, even when the surgery is planned. It's what we do; it's our culture; it's what we are accustomed to; it's our turf!
Well, it may be so, but it's also the birth of a human being. A woman becomes a mother, a couple becomes a family, or a family grows by one (or two, or more ;-}). I've read about calm, quiet, lowly-lit (for the emergence the baby) surgical births where the baby is delivered slowly, in full view of the mother and her support person(s), sometimes even to be placed on her upper chest before being whisked over to a warmer to be dried off, examined and bundled up by nurses or pediatricians; of babies who have even breastfed while the mother was being sutured post-delivery. Even in my own experience on a unit made sometimes over-conservative as a result of being a referral center for high risk pregnancies, I know of at least one physician, one who is conservative himself, who is frustrated at the business-as-usual way in which our cesarean deliveries are usually carried out. I suspect he would balk at the slow, dimly lit delivery with a newly born, wet baby being placed immediately on the mother, or of baby nursing during surgery (I can also envision the hysterics of our very conservative chief anesthesiologist, LOL), but I know he would prefer that we keep baby with the mother and her support people during recovery, and get breastfeeding initiated, rather than whisk baby away to the nursery after a few moments in Dad's (or whoever the mother has chosen for her support) arms, while he (or she) sat next to the mother. On a busy unit such as ours that can be a challenge...particularly because our recovery room has limited space and no infant warmers...but we have done it from time to time, for those assertive mothers who have requested it. It can be done. I'd like to see it done more often.
Likewise, I'd like to see members of ICAN be more conscious (although I know they already try to be) of the feelings of mothers who have given and will continue to give birth surgically. I understand the triumph of a woman who has "beaten the system" to have a VBAC; but that is not reason enough to, even unintentionally, and even sympathetically, view a woman who has had a c-section as a woman who has had a negative birth experience...who has not researched all of her options...who has "given in" to the system.
No, we don't want to risk normalizing surgical birth; but we certainly could benefit from humanizing it much more...both those who perform surgical births, and those whose (admirable) goal is to avoid it.
Tuesday, October 14, 2008
Monday, October 6, 2008
A Beautiful Birth
It's been four days since my last shift, and I'm still trying to find the words to describe one of loveliest births I've had the privilege of attending as a labor nurse. This kind of birth is so rare in the hospital environment; but the experience has reaffirmed my belief that if a woman truly educates herself, has trust in her body and the Natural Design of birth, and surrounds herself with the appropriate support, a minimally interventive birth can be achieved in the hospital. With the permission of the lovely couple and their doula, I am honored to be able to tell their story here.
The mother is a 32 year old woman G., who was laboring with her first baby. She was accompanied by her husband C., and her doula, S., a lovely woman who stayed by the side of her client nearly every moment of a long, long labor. I came on shift at 7:oo P.M., and the couple had been there since the late hours of the previous night shift. The report I received was that G.'s water had broken at 2:30 in in the morning (so we are now well over 12 hours) and that she, C., and S. had walked for hours trying to get labor started, until finally she consented to have her labor augmented with Pitocin.
When I entered the room, G. was in the throes of full, hard labor. The room was dark and soft music played from their ipod dock on the side table. The labor bed was bent into a "chair" position, with the top of the bed straight up, and the bottom of the bed lowered to support her feet. This was a woman who had determined that her labor would be accomplished on her own terms. She wore her own clothing, a tank top and a short "skirt"...it looked like it might have been a "Binsi" skirt (www.birthbinsi.com). She sat upright on the "chair"bed, bare feet planted firmly on the foot rest. S, a slender (thirtysomething?) woman with short blonde hair perched just behind her, one arm about her waist, the other on her shoulder. In front of her, C. knealt on the foot of the bed, while she rested her forehead on his chest, his hands placed around her shoulders in a soft embrace. Back and forth they all rocked, a single, loving, hard working entity, to the tempo set by G. as she groaned a low, throaty labor song with each contraction. As each contraction slowed, she would exhale and lean back into the S.'s arms, to accept a sip of water or a cool cloth on her face and neck. As another contraction would well up, she would again lean in towards C., S. would take her place behind her, and they would resume the rythm of their labor "dance". Occasionally G. would move from the bed to a birth ball beside the bed, and C. or S. would massage her lower back or perform a "hip squeeze" to help aleviate back labor. As time moved on, G. began standing beside the bed, bending over with each contraction, placing her hands on the bed and rotating her hips through each one. As each contraction would peak, her labor song would progress from a long low moan to nearly a growl...a "she bear", working to bring her baby into the world.
During each contraction (which S. would refer to as "surges"...appropriate, I think), G. seemed to move completely into her own world. As each surge came to an end, she would look up and brightly smile at one of her companions, crack a wry joke about her "situation", or, if I was in the room, ask a question or ask to be checked. What I loved about these times was that she would be completely calm and happily "present", as if the considerable pain she was experiencing during the surges had never happened at all.
One of the things I hear over and over again, from nurses, physicians, anesthesiologists, and from many women is why, with the epidural, women would want to experience the pain of labor. As a nurse, I struggle with complying with the wish of some mothers not to offer them pain relief until they ask for it. We're trained to treat pain. It's difficult to stand by and let it happen. My doula friend C. has helped me by reminding me that the pain of labor does not always mean "suffering". That has helped me when working with mother's who fully understand and want to work with their labor; but so many women equate labor pain with just that...suffering. I've listened to women who've arrived at the hospital with no time before delivery to get an epidural and heard their panicky pleas for "something, anything" to save them from their pain. They truly felt they were suffering. Sometimes I've been able talk them through their contractions, either with my voice alone, or with a visualization, and they realize that yes, they can do this...and they seem to cope better. Other times, no matter how hard I try, the woman is so tightly gripped by her fear of the pain, and of the process, that nothing I do seems to help. This is when I feel the most helpless.
I wonder if some physicians and nurses roll their eyes at a woman who has arrived at the hospital with a birthplan, or a doula, or both, because they are not accustomed to the woman being the one who is "in charge". We're used to setting the pace for labor, of determining in what manner the "outcome" will be achieved. When a woman and her support team call the shots, and call them appropriately, there is very little for us to do. Waiting and watching, listening and supporting, while it is the major role of a midwife, is not something that labor nurses get a chance to do much of; and it's not something that physicians are trained to do. I tend to make myself scarce during this type of labor; I figure the woman knows her support team and each knows what to expect of the other. Particularly when a good doula accompanies the woman, there is very little I can offer in the way of education and support. With G.,s labor, as much as I truly supported and admired the way she was accomplishing it, I felt like an intruder when I needed to replace the blood pressure cuff, or readjust the fetal monitoring system. She was very gracious though, and before long I began to feel welcome as a part of her "team".
Several moments stand out for me in my memory of this labor. The first is a "picture" I will forever hold in my heart. While G., C., and S. rocked back and fourth in their labor dance, there was a moment when C. laid his head against his wife's breast. G., her eyes closed, leaned back against S., face turned upwards, and S., as she rocked with G. in her arms, placed her cheek softly against G.'s hair, her eyes also closed, with a look of pure love on her face. My words do little to describe the sweetness of that moment. I so wished I had a camera to capture it for them. Later on in labor I was able to borrow C.'s camera and take a few photos as G. pushed, lying on her side, while S. and C. supported her, and the Nurse Midwife squatted at the end of the bed, smiling at the progress G. was making with her powerful, grunty pushes (no "hold your breath and count to 10" nonsense here...and she pushed for only 45 minutes. I wanted to pull every nurse and resident on the floor into that room and say "See, you can push a baby out without holding your breath !!!!! Of course I didn't, but I made sure to get the word around afterwards). At one point just a short while before G. began to push, she called me into the room and asked me to check her progress, because "I feel like I'm losing control". She wasn't though...in between those contractions she was as clear and "in control" as any one else in the room. I hope that pointing this out to her...that from my perspective she was maintaining perfect control...was something she was able to "hear" as she continued on in her labor. There were a few times when she would come out of a contraction and breathlessly exclaim "I can't do this any more"...but she was nearly complete at that point...a classic "signpost" of transition labor.
At 1:53 A.M...nearly 24 hours from the time G.'s water had broken...a beautiful little boy tumbled into the world and a family was born. He spent the next hour and a half cuddled next to his mother, nursing, snoozing, occasionally protesting. C. was ecstatic, and G., as exhausted as she might have been, instead seemed to experience a second wind. As she chatted and nursed her son, you might never have guessed that only a few moments before she was near exhaustion. S. continued her constant support of G., helping her position the baby for nursing, providing food and drink, and tidying up the room for the coming move to the postpartum room.
If only every labor could be like this; if only every woman had such a wonderful support team; if only every woman believed in herself the way G. did.
Welcome Little One. You are as fortunate to be born to your Mother and Father as they are delighted with you. I will forever be blessed for having been witness to your arrival.
The mother is a 32 year old woman G., who was laboring with her first baby. She was accompanied by her husband C., and her doula, S., a lovely woman who stayed by the side of her client nearly every moment of a long, long labor. I came on shift at 7:oo P.M., and the couple had been there since the late hours of the previous night shift. The report I received was that G.'s water had broken at 2:30 in in the morning (so we are now well over 12 hours) and that she, C., and S. had walked for hours trying to get labor started, until finally she consented to have her labor augmented with Pitocin.
When I entered the room, G. was in the throes of full, hard labor. The room was dark and soft music played from their ipod dock on the side table. The labor bed was bent into a "chair" position, with the top of the bed straight up, and the bottom of the bed lowered to support her feet. This was a woman who had determined that her labor would be accomplished on her own terms. She wore her own clothing, a tank top and a short "skirt"...it looked like it might have been a "Binsi" skirt (www.birthbinsi.com). She sat upright on the "chair"bed, bare feet planted firmly on the foot rest. S, a slender (thirtysomething?) woman with short blonde hair perched just behind her, one arm about her waist, the other on her shoulder. In front of her, C. knealt on the foot of the bed, while she rested her forehead on his chest, his hands placed around her shoulders in a soft embrace. Back and forth they all rocked, a single, loving, hard working entity, to the tempo set by G. as she groaned a low, throaty labor song with each contraction. As each contraction slowed, she would exhale and lean back into the S.'s arms, to accept a sip of water or a cool cloth on her face and neck. As another contraction would well up, she would again lean in towards C., S. would take her place behind her, and they would resume the rythm of their labor "dance". Occasionally G. would move from the bed to a birth ball beside the bed, and C. or S. would massage her lower back or perform a "hip squeeze" to help aleviate back labor. As time moved on, G. began standing beside the bed, bending over with each contraction, placing her hands on the bed and rotating her hips through each one. As each contraction would peak, her labor song would progress from a long low moan to nearly a growl...a "she bear", working to bring her baby into the world.
During each contraction (which S. would refer to as "surges"...appropriate, I think), G. seemed to move completely into her own world. As each surge came to an end, she would look up and brightly smile at one of her companions, crack a wry joke about her "situation", or, if I was in the room, ask a question or ask to be checked. What I loved about these times was that she would be completely calm and happily "present", as if the considerable pain she was experiencing during the surges had never happened at all.
One of the things I hear over and over again, from nurses, physicians, anesthesiologists, and from many women is why, with the epidural, women would want to experience the pain of labor. As a nurse, I struggle with complying with the wish of some mothers not to offer them pain relief until they ask for it. We're trained to treat pain. It's difficult to stand by and let it happen. My doula friend C. has helped me by reminding me that the pain of labor does not always mean "suffering". That has helped me when working with mother's who fully understand and want to work with their labor; but so many women equate labor pain with just that...suffering. I've listened to women who've arrived at the hospital with no time before delivery to get an epidural and heard their panicky pleas for "something, anything" to save them from their pain. They truly felt they were suffering. Sometimes I've been able talk them through their contractions, either with my voice alone, or with a visualization, and they realize that yes, they can do this...and they seem to cope better. Other times, no matter how hard I try, the woman is so tightly gripped by her fear of the pain, and of the process, that nothing I do seems to help. This is when I feel the most helpless.
I wonder if some physicians and nurses roll their eyes at a woman who has arrived at the hospital with a birthplan, or a doula, or both, because they are not accustomed to the woman being the one who is "in charge". We're used to setting the pace for labor, of determining in what manner the "outcome" will be achieved. When a woman and her support team call the shots, and call them appropriately, there is very little for us to do. Waiting and watching, listening and supporting, while it is the major role of a midwife, is not something that labor nurses get a chance to do much of; and it's not something that physicians are trained to do. I tend to make myself scarce during this type of labor; I figure the woman knows her support team and each knows what to expect of the other. Particularly when a good doula accompanies the woman, there is very little I can offer in the way of education and support. With G.,s labor, as much as I truly supported and admired the way she was accomplishing it, I felt like an intruder when I needed to replace the blood pressure cuff, or readjust the fetal monitoring system. She was very gracious though, and before long I began to feel welcome as a part of her "team".
Several moments stand out for me in my memory of this labor. The first is a "picture" I will forever hold in my heart. While G., C., and S. rocked back and fourth in their labor dance, there was a moment when C. laid his head against his wife's breast. G., her eyes closed, leaned back against S., face turned upwards, and S., as she rocked with G. in her arms, placed her cheek softly against G.'s hair, her eyes also closed, with a look of pure love on her face. My words do little to describe the sweetness of that moment. I so wished I had a camera to capture it for them. Later on in labor I was able to borrow C.'s camera and take a few photos as G. pushed, lying on her side, while S. and C. supported her, and the Nurse Midwife squatted at the end of the bed, smiling at the progress G. was making with her powerful, grunty pushes (no "hold your breath and count to 10" nonsense here...and she pushed for only 45 minutes. I wanted to pull every nurse and resident on the floor into that room and say "See, you can push a baby out without holding your breath !!!!! Of course I didn't, but I made sure to get the word around afterwards). At one point just a short while before G. began to push, she called me into the room and asked me to check her progress, because "I feel like I'm losing control". She wasn't though...in between those contractions she was as clear and "in control" as any one else in the room. I hope that pointing this out to her...that from my perspective she was maintaining perfect control...was something she was able to "hear" as she continued on in her labor. There were a few times when she would come out of a contraction and breathlessly exclaim "I can't do this any more"...but she was nearly complete at that point...a classic "signpost" of transition labor.
At 1:53 A.M...nearly 24 hours from the time G.'s water had broken...a beautiful little boy tumbled into the world and a family was born. He spent the next hour and a half cuddled next to his mother, nursing, snoozing, occasionally protesting. C. was ecstatic, and G., as exhausted as she might have been, instead seemed to experience a second wind. As she chatted and nursed her son, you might never have guessed that only a few moments before she was near exhaustion. S. continued her constant support of G., helping her position the baby for nursing, providing food and drink, and tidying up the room for the coming move to the postpartum room.
If only every labor could be like this; if only every woman had such a wonderful support team; if only every woman believed in herself the way G. did.
Welcome Little One. You are as fortunate to be born to your Mother and Father as they are delighted with you. I will forever be blessed for having been witness to your arrival.
Thursday, October 2, 2008
And I am Thrilled...
...for "AT YOUR CERVIX", as she begins a new journey in her life, the road to becoming a Certified Nurse Midwife...and a blessing to many women in the future. Check out her blog (again, click on the link in my "favorite blogs" section), and enjoy following it as she no doubt provides many wonderful, moving, hilarious, and educational stories of her journey...and be sure to leave a great big
CONGRATULATIONS!!!!!
in her comments section
I Am Humbled...
To know that women can communicate so eloquently and respectfully about a topic as important as a woman's decision to continue or terminate a pregnancy and all the issues surrounding it.
Please go to Navelgazing Midwife's blog (see my "favorite blogs" section and click on the link), and read her September 29 post, and particularly the comments. You will be richer for it.
Please go to Navelgazing Midwife's blog (see my "favorite blogs" section and click on the link), and read her September 29 post, and particularly the comments. You will be richer for it.
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