Tuesday, March 6, 2012

Surprise Breech Birth


Very interesting surprise breech home birth with a postpartum transfer.  It is a detailed story and I must say, it says a lot about birth, home birth, transfers, hospital care and treatment, and the current maternity system.  Truly, personal stories like this tell bigger stories about our culture and our views of birth and birth history-

Enjoy!

The birth of Callan Leo
LMP due date: March 17
U/S and conception due date: March 22
Born: March 29, 2011 @ 3:35 p.m at 41 weeks.
7 lbs 12 oz, 21 inches


Right from the very beginning, everything about Cal’s pregnancy was a test of my ability to accept life as it comes.

My husband and I knew we wanted a second child and planned to start trying for one in September, just before my first son turned two. A summer baby seemed so nice, but this baby wanted to be born in spring instead.

I definitely was not charting as I used to, but figured since I was on cycle day 20 or later, that the chance of conception while on a family vacation celebrating our wedding anniversary was pretty slim. But just before July 4, I noticed some tell-tale fertility signs and realized it was a little too late to prevent a possible pregnancy. Sure enough, a couple of weeks later I was woken with the urgent need to pee and discovered I could no longer drink even a sip of coffee or make it long without eating. I tested on July 17 and low and behold, we were expecting our second baby in March.

I knew immediately I wanted to make a homebirth happen. My first son’s hospital birth was the best I could ask for from that setting but it was stressful, not the comfortable or relaxing environment I wanted. I knew I would again birth without assistance from pain meds and therefore felt a hospital was utterly unnecessary in terms of the care I required for my baby and I. I also knew that for me, another hospital birth would necessitate laboring at home as long as possible and had no interest in making the mad dash to the hospital in active labor.

With my first, my labor began when my water broke and after only 6 hours or so of contractions I was getting copious amounts of bloody show and already feeling pushy. I was fully dilated and fully pushing by the time we arrived in antenatal. My 8 pound son was born after 90 minutes of pushing at 3:26 p.m. It was pretty fast for a first baby and all involved agreed a homebirth might make the best sense for my second, assuming my pregnancy was as low risk as my first was.

I began my second pregnancy with the same midwives from my first, knowing I would eventually have to transfer to a midwife who would attend my baby’s birth at home. So I set out to find that midwife, interviewing five possibilities while receiving prenatal care from my old CNM. We did all of the routine prenatal testing including the early risk assessment ultrasound and anatomy scan at 20 weeks while we knew my care was safely covered by insurance.

Meanwhile I was also sorting out insurance and trying to make every possible preparation for my home, health and family to ensure to the best of my ability, that birthing at home would be safe and peaceful.

There were constant tests of my decision along the way: from questions about whether my insurance would ultimately pay for most of this or whether it would be entirely an out of pocket expense; questions from friends and family about our choice to birth at home; questions about my choice of midwife and whether or not to consent to various prenatal care options in the later part of my pregnancy. Questions about birth pools even! I did a lot of soul searching and research--more so than I did even with my first pregnancy.

The last two weeks of my pregnancy were the toughest. I was really feeling doubts about my body working that I’ve never experienced before. My mom, a labor and delivery nurse for more than 30 years, was staying with us so she could attend the birth and help with our son. But having her there was bringing out the worst in me in so many ways. It seemed as soon as I would get myself back into a peaceful mindset, someone would say something or I would read something that would just slam me back into this doubting place. It was really taxing.

Most of the stress stemmed from my foolishly convincing myself that this baby was going to come early. My first son was born a week before my earliest due date and none of my sisters’ six babies were born post 40 weeks. I for some reason believed it was impossible for us to gestate babies longer than that! So when my first due date came and went, then my second came and went, I got a great big taste of how agonizing it is for women to go post dates.

The single best thing that did come out of the wait was that my husband became critical to me in terms of my dealing with the stress. I am fiercely independent and often resistant to leaning even on him, and he totally showed me that I could and should rely on him more. I think we needed that for our relationship and that bond would end up being really important to me later in ways I only really grasp now.

41 weeks
By 39 weeks I was having fairly regular but inconsistent contractions. The kind that have you convince that labor MUST be imminent. But I ended up experiencing a good two weeks of this sort of labor pattern: A day of really minor early contractions that followed no pattern, followed by a day of absolutely nothing. I sat on my birthing ball, tailor sat, did pelvic rocks, took long walks including hills and curb walking, everything I could think of to coax labor to begin in earnest. Nothing was working.

My midwife and I decided that if I was still pregnant at 41 weeks, we would get an ultrasound and biophysical done to check on the baby. But once again, baby had his own plans. On Sunday morning, March 27 I woke up at about 7 a.m. to a subtle gush that reminded me of my water breaking with my first son, only it really wasn’t much fluid and unlike last time, I wasn’t able to force more out by pressing on my belly. I rested there with the cat and felt a few contractions come and pass thinking we might finally be in labor. When my husband and son woke up later, I told my husband I thought today might be the day and was overcome with a feeling of readiness that was so reassuring. I didn’t feel stressed in the least. We even called my cousins and asked them to be on standby in case we decided to send our son to their house. I was so sure things were happening. But after a good long walk up hills and home, it was clear this was just another warm up labor and not, in fact, the real thing.

Clearly discouraged and even a little depressed, my parents decided to spend a night at my brother’s house to give me a little space. On Monday they returned because my mom had a dentist appointment right by my house and despite not feeling well, intended to go. She looked pretty exhausted and had really bad stomach issues that we were pretty sure was the same GI bug my brother’s son had recently gotten over. I felt terribly for her and yet was thinking to myself, ‘man, she probably shouldn’t be in my house right now.’

My husband cooked us all dinner and my mom hardly ate anything before going off to bed at 8:30. More than once I thought to myself: ‘great, now after weeks of dodging illness we’re all going to get a GI bug and my labor will be delayed even further!’

Or maybe not… I went to bed myself a couple of hours later and was woken at 2 a.m. or so to a contraction. As I lay there I felt another come and pass… then another and somewhere around 3 a.m., felt a real gush of amniotic fluid. I immediately turned on the light so I could tell whether the water was clear and so I could get to the toilet before the rest of the fluid released (this was exactly how my labor started with my first son). As soon as I stood up I made a puddle on the floor instead. I removed my white sweatpants and used them to clean up the mess and further confirmed there was no meconium staining or obvious reason for concern.

I popped into my son’s room where my husband was sleeping and gave him the news, then decided to just relax in bed and see what happened. I wasn’t getting real strong or regular contractions and wanted to let everyone sleep as long as possible. I felt pretty calm and good until I felt this pulsing sensation low in my pelvis and for some reason immediately worried that it might be his cord. I reached for my perineum and felt something that wasn’t my body. It was really thin and didn’t really feel like a cord to me but it sent me into a brief panic so I decided to call my midwife for her opinion.

Because I had to go downstairs to get her number, I had to wake my dad who had elected to sleep on our couch to give my sick mother some solitude. I assured him I was ok and sent him up to sleep with her while I spoke to my midwife. She convinced me a cord would be unmistakable and upon investigating further it was pretty obvious what I was feeling was probably some amniotic sac (I could even press more fluid out of it.) She asked if I could feel the baby moving and as if on cue, I felt our son turning his head on my cervix and felt him move his foot away from my hand when I played with it on my right side. Now feeling MUCH calmer, I let her off the phone with the agreement I’d call her back when things got more active.

Labor
At that point I had the downstairs to myself. I made myself some toast and decided to sit on the birthing ball and tie up some final work things that I had planned to do that day. I had always planned to work right up until labor began but ended up working from home for the last week of my pregnancy. I had actually just told my boss I planned to make March 29, or the day I hit 41 weeks of pregnancy, my final workday. My stubborn son, the one who insisted on being born an Aries instead of a Pisces like his mama wanted, obviously changed that plan too!

I was casually timing the contractions while finishing up work—ten minutes apart, not quite a minute long—then at approximately 5 a.m. I felt sleepy and like the contractions were mellow enough that I wanted to try and nap. I managed to sleep from about 5 a.m. to 7:30 or so which was great.

Around then the whole family was waking up. My parents decided to take my son out for the morning so my husband and I could have some peace and quiet. I sent my husband back up to nap and spent the morning letting myself labor to the Beatles and picking up here and there. The contractions started out really slow when I first woke but by 11 a.m. they were regularly at least a minute long and between 3 and 7 minutes apart.

I was just jotting down when they started on a pad of paper in between frequent trips to the bathroom and decided I wanted to use the contraction master web site so I could get a fuller picture of my labor patterns. The laptop was on my dining room table by the stereo so I stood behind my son’s highchair, using it for support when a contraction came, kind of grooving out to the Beatles in between. I was honestly having a lovely time.

Sometime really soon after my moving over to the table, the contraction intensity kicked up quite a bit. They were still pretty spaced out – about 8 minutes or so – but much longer and harder to breath through and I was feeling the contractions intensely focused right on my cervix. It felt a bit like someone was driving a hot piece of steel through my cervix at their peak: a lot more intense feeling than my contractions with my first son. Those ones radiated around my lower belly in textbook labor pain fashion. And while they had a peak to them that was quite painful, I didn’t experience any of this cervical sensation with him. I recall wondering if maybe baby #2’s hand was by his head? Something felt different.

At that point I asked my husband to come down and join me and not long after that just got this overwhelming wave of vulnerability and fear that labor was starting to get really fast. My first son’s entire labor and birth lasted 9 hours – I knew this could kick up in intensity quickly.

I decided to call my midwife then and ask her to come over and as soon as I picked up the phone to call her, I started crying. My voice totally gave her the impression I was ten seconds away from pushing and I seriously had her at my door in what felt like minutes. Really, she arrived at about 12-12:30 p.m. Our backup midwife came right behind her.

Of course just having them at the house set my mind at ease and things mellowed out a smidge again. She listened to the baby who sounded great and let me listen too. Checked my blood pressure (120 / 60, higher than it’s ever been but still normal) we checked his position: still ROA / head down.

She did not check my cervix, nor did I ask her to. With both pregnancies, my cervix was only ever checked when I got the urge to push just to be sure I was in fact fully dilated at that point. I had no interest in knowing how dilated I might be: that information always seems discouraging to me rather than helpful and I didn’t see any reason to introduce a possible infection considering my water had broken so preferred to leave that whole region alone.

Around 1-1:30 p.m. my mom returned with my son and two sisters. This was a little unexpected. I had previously told both of them I was ok with them being there for the birth thinking the likelihood they would actually make it was slim. But then the friend I had arranged to be there to take pictures and back up my mom with our son, was a no show and my mom really did need some support since she had been sick the day before.

My midwife checked in with me to make sure I was ok with all the people in the house and I assured her I was. This point is actually my favorite memory of the whole day: My mom, sisters, husband, son and the midwives all sitting around my table chatting and laughing. I was even able to joke, chat and snack with them in between contractions. This was exactly what I envisioned when I thought of a homebirth.

My husband, the midwives and my mom took turns supporting me through contractions and the midwives would periodically check the baby’s heart rate. Every other contraction I had to pee and would go upstairs and hope for some bloody show or signs things with moving along. I got a small amount of blood tinged mucous around 2 p.m. but not much. I asked my midwife when she thought it would be ok to get into the tub and she said, I should feel free to get in whenever I felt drawn to but that it can theoretically slow things down. My demeanor between contractions and how spaced out they were definitely didn’t let on to any of us that things were that far along. So I elected to keep laboring upright, sitting on the couch or standing until my mom made the suggestion to try laying on my left side. She told me later that she made that suggestion thinking that it might help coax the baby into a better position for birth.

Laboring like this was excruciating and after my second contraction in that position I told myself not to stay like that long. But the rest it was allowing me between contractions was too nice to motivate myself to get up so I stayed for a few more. My son was starting to want more of my attention so my mom and sisters decided they would take him out for a walk: my mom saying when she left, “call me when she starts pushing.”

The moment they closed the door, things went from a 5 to ten in intensity. My husband was by my side helping me through a contraction and something happened. I just felt this crazy sensation that I honestly don’t have any good memory of to describe other than to say it felt excruciating and before the contraction even hit its peak, the rest of my bag of waters exploded out of me, I got a serious Charlie horse cramp in my left hamstring and I immediately felt my son’s body move way down and the need to push.

I exclaimed something, “pushing!,” I think. And my midwives jumped up and got the tub cover off and started prepping for the birth. I didn’t want to move because what I was feeling was so intense but when I managed to get a break in between the urge to push, my husband helped me get into the tub.

Time To Push
The water felt amazing! And I pushed with the next contraction on my knees and could tell my son was going to be born pretty quickly. My midwife wanted to do the requisite cervical check and this is when things got really interesting. I was indeed fully dilated and baby boy had turned frank breech.

I think what I said then is, “Is that bad?” or maybe, “what do we do now?” My midwife reassured me we could deliver him, she’s delivered numerous breech babies before, in fact this was one of the things that attracted me to her in the first place not EVER thinking it might be necessary. But then when we checked my son’s heart rate again, his rate had dropped from the 120s to 80-90. This kind of heart rate change is not unusual at this point in labor but it was not comforting given the circumstances. We all agreed it was probably for the best that we transfer and so our backup midwife called 911.

Everything that happened next was a rapid, whirlwind of activity and given my role in all it, I can’t really claim perfect accuracy. All I can tell you is the whole process of my getting in the pool and delivering my son was about 15 minutes. Any pondering how I felt about it all was done later. In the moment, I was on autopilot just doing what felt necessary to deliver my baby or following the suggestions of others. Some of this I only know clearly because I asked what happened after the fact.

My husband called my mom to tell her what was going on and went about gathering up some clothes for me while my midwives discussed whether to get me out of the tub before EMS arrived. They wanted me to breath through the pushing contractions and not actually push, which I was able to do once, maybe twice, but after that it felt damn near impossible to not push that baby out. They both felt like keeping me in the tub would keep me more relaxed and hopefully slow things down: the goal being to avoid me delivering in the ambulance which everyone agreed was the least safe option. They gave me oxygen during this time, had me change positions and the next time they checked my son’s heart rate it was back in the 120s.

At that point my midwife felt things were moving much too quickly to make a section possible even if we were able to make it to the hospital (my son’s entire hips were through my cervix by then: I could feel his butt and testicles about an inch in.) So with his heart rate again where it had been all along, she gave me the go to just push. The backup midwife called back EMS to request that they wait outside until the baby was born.

Not long after that, maybe two-three pushes? His body was entirely out. His head was another story. At that point my mom is there and soon after EMS came in (I guess they didn’t heed our midwives’ request). Getting his body out was remarkably easy and other than the first moment of his hips coming through my perineum, was surprising not painful. I felt most of his body slip out but his head was still inside and I couldn’t feel it at all which totally confused me.

I knew, both because it was instinctual and because I could see my backup midwife’s face in front of me, that we needed to get his head out ASAP. I pushed with everything I had and it seemed nothing was happening. So my husband lifted held me up out of the water so my backup midwife could apply pelvic pressure without my body moving away from her hands in the water. My mom had one leg and an EMS worker had the other while my midwife managed to get her finger in my son’s mouth to get his chin towards his chest (a flexed chin makes birthing the head more difficult). Some combination of all of this got his head out but that time between when his body was out and his head was in felt like an eternity. In reality it couldn’t have been even 5 minutes.

My midwife brought my baby up onto my chest and he immediately looked up at my husband and I but then promptly went limp and clearly wasn’t breathing. They gave him breaths with the resuscitation bag while we talked to him and rubbed him and let the cord stop pulsing. My husband then cut the cord and they brought him over to the couch so everyone there could be assured he was breathing well.

This was unquestionably the hardest part. I was in the tub and couldn’t see anything. My husband talked in my son’s ear while our midwife continued giving him breaths with the bag and an EMS worker warmed him with warm towels/blankets. His heart rate was apparently strong through all of this and he was breathing without help within minutes. Throughout this time, my midwives and one of the EMS workers were giving me updates but I feel like I was in space somewhere. People periodically asked if I was ok, and I said I was but I remember feeling kind of numb. Not scared, somehow knowing he was fine and yet not fully knowing that at the same time. Just stunned I guess.

Because of the crazy eventfulness of it all and the fact that our baby needed help to breath in the beginning, we decided to take advantage of the ambulance and make a trip to the hospital to have a pediatrician make sure my son was ok. The EMS team had brought him into the ambulance before I was even out of the tub so I didn’t get to see him again until they got me out, dried off and into the ambulance. By then everyone was assuring me he was crying vigorously and was completely fine. I finally got him back in my arms and could see that for myself while naked under a pile of blankets on a stretcher.

Postpartum Hospital Transfer
We transferred to Brigham and Women’s hospital over the one where my first son was born because the ambulance could only go to hospitals within city limits. At this point it was only a precaution to make sure Cal’s breathing was ok. He received an APGAR of 10 when we finally got to our room and latched on and was nursing almost immediately. A pediatrician checked him out and said, other than breathing that was a little more rapid than they would like, he seemed perfectly healthy. They just wanted to evaluate him again after four hours to see if his breathing rate returned to normal range and at that point we were free to head back home.

He looked fantastic, super alert and not remotely health compromised to the point where as soon as we had a moment to collect our thoughts it felt beyond unnecessary to even be there. The only sign of what he had gone through were his huge, purple balls and a big bruise on his hip from that being the presenting part during pushing. My midwives noticed his head had some really unusual crowning on the back. His head was shaped kind of like ET’s, which can be typical of a breech baby, but you could also feel this ridge at the back where his fontanel sutures molded. He was facing my rear so I’m sure it was this getting lodged on my pelvic bone that made it so tough to get his head out. Not to mention, we later realized his head was in the 98% in size! (Still is! Doesn’t look like it but baby boy has a big head!)

Our nurse upon checking in was absolutely awesome. Such a nice lady and really laid back, supportive and not judgmental. She was like the bright light of our brief stay at BWH. Sadly we were catching her at the end of her shift so we didn’t get to enjoy her for long. But she was so awesome, I can’t not mention her.

EMS wanted to get Cal and I on the road quickly so I had yet to birth the placenta. As soon as we got in the room my midwife was encouraging me to try and squat and push it out before the OBs started to make their own suggestions.

The idea of squatting at that moment seemed semi impossible but I had Cal on the boob and his sucking got a good contraction going so I was able to push it out pretty easily while reclining. My midwives, my mom and the awesome nurse all checked it out and declared it intact and no one was concerned about the amount of bleeding I had. There was a little membrane left hanging out of me that my midwife gently worked out with her hand in case it was attached to placenta or something. I felt immediately better once the placenta was out!

Moments later an OB, about my age, came in to tell me that, “she would feel better if she could do an internal exam.” Meaning without even looking at the placenta, she wanted to reach both her hands up into my uterus to check for retained placenta. She had two L&D nurses and two midwives telling her that there was absolutely no reason to be concerned about retained placenta but SHE would feel better if I would consent to her sticking her hands inside my body where nothing other than my child had been before. I’m fairly sure my jaw dropped and I flatly refused. Awesome nurse basically schooled her (with back up from the three other trained medical professionals in the room) and that OB hightailed it out of there and fortunately we never saw her again.

I’m still aghast that this woman would even suggest that though. I can’t help but think of a woman in my position with less support or less familiarity with what is appropriate. I can’t imagine why she would subject a woman to that kind of painful, invasive procedure without even a cursory glance at the placenta first to be sure it was medically indicated. It’s insulting if not abusive.

Once that event was behind us, the parade of residents began. At first I wondered if some sort of memo had gone out: ‘hey, homebirth transfer in room 505, anyone want to practice some gyno procedures?’ But after talking with a few other moms that delivered there, I guess this is not so uncommon at teaching hospitals. They came in in pairs and all wanted to check out my under carriage which my midwife had already given me a report on.

I had definitely torn but was also pretty swollen at that point so it was tough to get a really good gage of how bad the tear was. My midwife felt it made best sense to get it repaired by an OB while I was there so that I could be more mobile, more quickly. Plus, she wasn’t positive there was no involvement of rectal muscle, which needs to be stitched.

The line from my parade of residents was: “We think this is going to be a fairly significant repair and that you will not be able to tolerate the procedure without an epidural.” Seriously: No fewer than six residents and two OBs came into my room on at least three occasions and tried to convince me to agree to an epidural (or at least IV morphine) before they attempted to stitch me up. One OB said the only reason why I was able to deliver my breech baby without drugs was because of endorphins and that there was no way I would be able to sit still for stiches using local anesthetic alone because ‘no woman can.’

Of course this part I love, because apparently I’m super woman (I’m not.) But I told them from the very beginning the drugs were completely off the table. Another favorite quote from one guy resident: “Can I ask why you are reluctant to get the epidural?” I can’t even remember what logic I gave him. In my head I was just thinking, “How about you just accept that I just don’t feel that I’ll need one.”

And I really didn’t need one. I had 5 stitches after my first son’s birth and while this tear appeared worse, it didn’t appear to be massively so. In fact there was a lot of debate over what degree it was.

Finally they relented and got ready to stitch me up with lidocaine injections alone. Getting the shots was literally the only discomfort I felt and it was nothing. And because a resident was the one stitching me up, the whole procedure took way longer than it needed to take. I received 8 stitches and it was ultimately concluded I had a borderline 4th degree tear because there was very minor rectal muscle involvement but generally the tear was pretty shallow. I do suspect it was truly pretty minor even if it was technically a 4th degree tear. I had no discomfort during recovery and was up running around the next day. I only iced the area once and never felt the need to take ibuprofen.

In hindsight it seemed more like the push to get me to relent to an epidural was so they could guarantee a docile patient for the resident to practice on. I can’t verify that but I’ve had other people confirm my suspicion.

Back at Home
At this point we were ready to head home. I had already been up to pee and felt great compared to my first son’s birth when I had actually had a minor hemorrhage.

My midwife came to pick us up in our car and we were back home by about 9-10 p.m.? My midwives and my family had cleaned up so my husband and I could just relax at that point. We were obviously pretty tired but I was still a little too wired to go to sleep so we sat in the living room for a little while before taking Cal to bed and finally falling asleep a family of four.

It’s been almost a full year since my son was born and I’ve spent a lot of time trying to process it all after the fact. It was just so far from what I had envisioned--as birth always is--and not without its moments that are incredibly hard to think about.

Overall my husband and I are relieved we chose to birth at home and not for any of the reasons why we chose home birth to begin with. And at the same time, I definitely have felt some serious sadness over how far Cal’s welcome into this world was from what I had hoped for him. I’m deeply aware these things go as they go and feel nothing but gratitude for the beautiful, thriving baby boy in my arms and everything giving birth to him has taught me.

The first question I’m always asked though is ‘would I choose home birth again.’ The short answer is not unless our healthcare system changes to the extent where homebirth is covered by health insurance and care can be seamlessly transitioned back and forth between care providers.

I personally found it really stressful having to worry about what procedures may or may not be covered and the fact that in my state (MA), home birth midwives cannot legally carry things like antibiotics.

That said, I do not at all feel like my son’s birth would have been less eventful if we had birthed in a hospital. I think most people assume I would have had a section if I had. But I’ve since had multiple conversations with OBs and the CNM that delivered my first son and it seems we potentially avoided a really scary situation: a care provider faced with a vaginal breech delivery that had never delivered one before.

A common cause of serious injuries from vaginal breech birth is aggressive measures used to deliver an entrapped head. My midwife knew how to deal with that exact complication and because of that, I have a perfectly healthy baby boy who just happens to be a little stubborn about how and when he does things. It’s totally possible I could have had one of the few care providers at my old hospital with the same skillset, but it’s more likely I would have had one who only knew one way to deliver breech: with a scalpel. Trying to shove Cal back through my cervix to deliver him that way does not sound safer to me!

2 comments:

Kimberly O. said...

What an amazing story. For what it's worth, my EMTs were pushy too.

Also, your son has one of the best birthdays ever! He shares a birthday with my oldest daughter! :)

purerandomness said...

So glad you decided to share this! I think it's such an amazing story. :-)

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