membranes

To me, the amniotic membranes are an amazing and beautiful thing. They embody the concept of strength in flexibilty. Being so incredibly thin and yet such a tough defender of the babe. Keeping the baby tucked inside; encompassing the salty, warm, nurturing environment of the womb. When I do vaginal exams during labor, and I feel that filmy, slippery membrane I am constantly in awe of its power. The veil at the doorway that separates our two worlds.

Working as a nurse in the hospital, I was constantly shocked at the often flippant way the membranes were regarded. So easily ruptured with little to no explanation to the mother as to why. Sometimes, even 'just done' and not even mentioned until after the break! Such a routine intervention, to the point of not really being considered an intervention.

As a midwife, I have used AROM (artificial rupture of membranes), but very sparingly. To me, it is a serious intervention and one that significantly impacts the babe's experience....a sudden, potentially jolting change. Don't get me wrong, sometimes it is an appropriate and helpful intervention. I just don't like the 'routine-ness' of it. When I have done it, it has been after careful consideration and thoughtful discussion with Mama and her partner. I have had several couples, after this discussion, decline the AROM. In my experience, the membranes most often release on their own, in their own time...and sometimes they don't release and the babe is born with them intact. I have caught 3 little ones this way. (see a previous post about the significance of this) I have had some Mama's who, from previous experience, have thought that the membranes had to be ruptured for the birth to happen...that they would hold things up and get in the way. A very popular question from family members when they feel things are 'taking too long' is "aren't you gonna break the bag?" This has become part of our culture of birth and cultures are a hard thing to overcome. Let's see if we can work on this one....

the shoulders

I have often been told that as a student, we all have a "hang up", a scenario that we fret over. For some it is a postpartum hemorrhage, a surprise vaginal breech, a serious baby resuscitation, etc. For me it was always a shoulder dystocia, a complication where the baby's shoulders become 'stuck' behind the mothers' pubic bone. It can be a potentially serious situation involving long term damage to both Mother and Baby. I have always been drawn to reading anything and everything that I could about this situation. Whenever I have been at conferences or gatherings of midwives, I was always present at discussions about 'shoulders'....always trying to suck up and store any tidbits of wisdom. As a student, I thought that I had had two cases and then I thought that I had another two cases as a midwife. The optimal part of those cases is that "I thought" I had had 4 shoulder dystocia's. My first clue to the error in my thinking should have been the number.....4 is a lot of these to have in a short period of time, as this is a relatively uncommon complication. Additionally, in all four situations the problem was resolved pretty quickly, less than 30 seconds, and with very mild intervention. You see, before Jenny's birth, I thought I had dealt with 'shoulders' before.....

Jenny was a first time mama, a sweet petite little lady with a supportive and tall, lanky husband. Her labor was nice....lots of moving and grooving, moaning and singing. She progressed nicely and at a good pace. Then she entered second stage and her nice progression stalled. She pushed and pushed and fought for every little gain. Finally, Jenny had worked her little one to crowning, and still the progress slowed. Of course, this second stage pattern is a classic 'warning sign' for shoulder dystocia, so I was mentally preparing for it. Running the drills in my head, telling the nurse to be ready with oxygen and to help with interventions. We were 'on alert' and ready. Then we were given the "turtle sign" from the babe...this is when the head emerges and then quickly retreats back into the perineum, like a turtle retreating into its shell. This is the ultimate and supremely classic sign of a shoulder dystocia, and I had never witnessed such a clear and obvious example of it!

Very quickly, we had Jenny get into McRoberts position, which for my previous 4 cases had worked like a charm. Absolutely no descent from baby. Very quickly we had Jenny move to the Gaskin (hands and knees)...again, absolutely no improvement. I passed my hands into Jenny's vagina to attempt and feel the baby's shoulders...I ran my fingers up the neck...and up and up...I could not feel the shoulders!!! They were so far back, that I could not feel them. This is when I realized that this was my first true shoulder dystocia and the tense set in. In certain situations I have experienced that time can simultaneously speed up and slow down...this happened on this night. My vision became crystallized and focused, like intense tunnel vision, the world became Jenny, her baby and her vagina...nothing else existed. In some ways, I switched to auto pilot...the drills, so long practiced and held in my mind, became my only thoughts. I worked through several maneuvers and could not get the shoulders down, could not find the arms. Jenny was amazing and followed my every direction to a tee and my nurse was fantastic...however, this baby would not budge. I had to remind myself to breathe...time ticked by...baby was not coming....after the failed attempts to free the shoulders, my hands took over. I reached deep inside Jenny, the baby held between my palms like a prayer...please Creator, help me, help this Mama and her Baby, please work through me, please, please...and then I finally found it, the baby's posterior arm. I was then able to both pull that arm out and rotate the baby like a corkscrew and with one final big push from Jenny, baby was free! What seemed to have been an eternity had lasted for three minutes...baby was stunned and needed a little encouragement, but came around nicely. He weighed in at 9# 13 oz....pretty big for a petite little Mama. Amazingly, somehow, Jenny's vagina and perineum were intact! Jenny and her husband were elated and Jenny's husband made a comment about how when he was born, he had gotten stuck and the doctor had to break his collar bone to get him out! (The nurse and I both had a little nervous laughter fit over that one later.) The new "little" babe wasted no time in locating his mothers' breast and then camped out there for hours, happily nursing away.

So, there was my biggest fear....faced and, at least for this time, conquered. Jenny loved her birth and remembers the nurse and I being very calm, focused and reassuring during the experience. I am eternally grateful for all the books I had read, all the midwives wisdom that I had soaked up and for the support of divinity in the room.....

the unkown milestone

This transition from student to midwife is a hefty load....of course it should be and I did not expect it to be easy. From the beginning, I had a feeling of floating around, with my feet way ahead of me or way behind. I was constantly attempting to catch up with them...or slow them down....just to get them underneath me. Recently, I hit a milestone that I had not expected or even thought about. After the last lovely birth, while writing the experience down in my midwife journal, I realized that I have now caught more babies as as midwife than as a student. This realization hit me profoundly and like a ton of bricks. I had not known that this moment would be so special and perhaps the surprise of it made it even more special. Sitting there, looking at my journal I shed a couple tears...of happiness of gratitude and of excitement. Since then, I have been able to have the feeling of my feet being right underneath me, strong and stable. Granted, I have many years of learning and growing ahead of me, and I am not going to get cocky about myself. However, I do finally feel like a 'real' midwife....which really means that I am very aware of my newness....but I am also aware of the strength and knowledge that I do have.

the 2X4 of birth humility....

Wake up call at 5am, two Mama's at the center, both first time Mama's whose water had broken in the night....Little did I know that I was destined to be hit over the head with the cosmic 2X4 of birth humility by one of these sweet ladies....

Molly is a lady that I had really liked during prenatal visits. She had come in at around 5am because her water had broken and she was GBS positive, so she needed some IV antibiotics. Her labor started after her water broke. My midwife sister had checked her cervix and found it be 1cm dilated and described it as pretty tight. Molly was having a very difficult time working with her contractions, which were about 1-2 minutes apart and lasted for about 30-45 seconds. This pattern is usually not very effective, difficult to work with and often associated with some dehydration. Molly was having a hard time drinking and had thrown up, so since she already had an IV for her antibiotics, I gave her some fluids. Additionally, even though she was so early in labor, we put her in the pool to try and calm things down and give her a break. These interventions did very little to give her any relief. Three hours after her first cervical exam, Molly was working very hard and requested another cervical exam. I was worried that she would not be very much more dilated and that would really disappoint her and I didn't want her to get discouraged. We talked about it, but Molly really wanted me to check her, so I agreed. I placed my fingers in her vagina and....bonk!...baby head with just a little rim of cervix!! So, wham-o...the back of the head hit with the cosmic 2X4...silly, silly midwife!...never assume anything about birth! A tiny bit later and Molly started pushing, 31 minutes later and she had a gorgeous 9#1oz. baby boy in her arms!!!

Molly had been amazing and unlike some Mama's who have fast labors and then have a hard time afterwards, she was just so elated and very quickly had a little happy nurser snuggled up in bed with her.....

transfers

I have a strong faith and belief that birth is a natural process, that women are strong and babies are wise. That when a healthy women is nurtured and supported through the journey, she will most likely have a powerful and transformative birth experience. As a midwife, these beliefs are central to my philosophy. The catch to this faith is the "most likely" part of the equation.

My last several shifts have all involved the transfer of a woman in labor. I have become much more comfortable with the transfer process and much more trusting of my judgements in relation to the necessity of a transfer. However, that does not make them much easier in the moment. Midwives are sometimes referred to as 'guardians of birth' and this is a statement that I hold dear. As a guardian it is my job to, as much is possible, protect the mother and baby and to make difficult decisions when needed. Sometimes, in order to provide the safest care possible, that means a trip to the hospital. We have a saying about labor where I work, "its not birth center or bust". Meaning that our goal is a healthy mom and a healthy baby and for some families that means that we need the type of support that the hospital can give. Knowing this is beneficial, but in the moment, when I am supporting a woman and we have all been working very hard it doesn't make it any easier. When I have to look into her eyes and her partners eyes and tell them that the birth center birth thay have been planning and envisioning is not possible...that is a heart wrenching moment regardless of the facts. Ultimately, my goal needs to be the final outcome of a healthy Mom ready and able to care for her healthy baby and for them to grow together....and no single experience is worth that.

fast labors

Many times, I will hear women say that they hope for a very fast labor. This is deffinitely a situation where I will say "be careful what you ask for", just because it goes fast does not mean it goes easy. An example.....

Got a call from a second time Mama, Brenda. She sounds pretty hot and heavy over the phone, so I recommend that she hurry on in. About 20 minutes later, I am in the center, anxiously waiting for her. I think I hear sirens in the distance and think "Oh my gosh, she has had her babe in the car, down the street and here comes the ambulance!" I go outside to see if I can see anything.......low and behold....the siren I thought I heard was actually Brenda! She is in her car, in the parking lot and seriously cranking out contractions! With much ado and convincing, we (myself and her doula) coax her into the center. Her labor is loud and vocal, she is very confused about it being so fast. She has a lot of moving, using the swing, pacing and in and out of the birth pool....in essence she is trying to run away from her labor. Many, many times she states that she in not ready, that it can't be happening so fast, etc.... and all this very loudly! With much support and eye contact we are able to talk her through it and very quickly she is in the pool and crowning. THEN, as I am doing some perineal support, she takes my hand in hers and attempts to push the baby back up!! Saying, "it is just not time yet!" Of course, she was not able to stall very much and soon we had a happy 8# 40z boy to welcome to the world. Start to finish, her labor was less than 4 hours. After the birth, Brenda had a very difficult time accepting that her new little one had arrived and spent an hour processing before she could really enjoy him.

So, if a lady asks and hopes for a fast labor...remind her that through the process, we all have to pass certain mile markers and we can either pass them at regular pace or at 200mph...which can be very overwhelming and leaves little time to absorb the trip....

a day in the life #2....

So, if you were able to read the previous post, I said that I would be writing about two different shifts. For both of these shifts, I was basically at the center for 24 hours. However, they were both very different in how they played out.

Phone call at 5am...my midwife sister has been at the center for a couple few hours and caught one baby, another Mama will be having her baby soon. Additionally, another one of my midwife sisters is ill and, if possible, I need to cover her clinic schedule. Oh, and we had a Mama whose water broke the afternoon before and I'll need to check in with her and hopefully be with her in labor...sounds like a busy day....

While I was on my way in, my phone rang and it was the midwife who had called me earlier. Apparently, she had 'pocket dialed' me and I was able to hear her and a Mama in what sounded like the bathroom, having a baby! I listened for a little bit and then hung up the phone. A while later, the midwife called me back and we laughed about it. We decided that I should stop at Starbucks...since I had time now...and get some treats. With the type day of I had ahead of me, a little morning treat seemed in order.

When I arrived at the center, there were two lovely Mama's and their two new little boys all snuggled up and warm. I checked in with both of them and the nurse who was helping to care for them. Then, I went over to the clinic to prepare the charts of the clients that I would need to try and see for our sick colleague. It was a full day, with a lot of clients who all needed some sort of lab work...gearing up for a busy day.

At 8 o'clock, I got a call from Sue, the Mama whose water had broken the afternoon before. She was doing well, having some contractions but not really in active labor. We had given her some instructions for trying to get her labor started which she had tried. Our policy at the center, is that if a woman's water breaks, and the fluid is clear, she needs to be in active labor within 24 hours. Sue's time would be up at 2pm. Since it was now 8am and not much was happening, I decided that she needed to come in. We decided that she would arrive at around 9:30. I would not be able to cover the clinic day.....I saw the first three clients and then we had some serious shuffling to do. Which, thankfully, because we have amazing staff, we were able to do.

Sue and her husband arrived right at 9:30. She was having contractions but they were pretty short and pretty far apart. Her little one sounded great, the fluid was clear and her vital signs were perfect....we just needed some labor! I checked her cervix and it was only opened a slight little bit. We did a lot of talking about the chances of her being in active labor by 2pm and the probability of needing to go to the hospital. Clearly, this was not a fun conversation and we all had frustration and disappointment to work through. We decided that we would still try some tricks and hope for the best. We did some herbal tinctures, some walking, and used the breast pump. We were able to get some more contractions going, but they weren't enough to change her cervix. Finally, we made the tough decision to head over to the hospital. Luckily, I was able to call the midwifery group who works there an they were able to accept her.

Sue and her husband decided to use one of our on-call doula's to come over to the hospital to help support them. While I was there with them waiting for the doula to arrive. I got a call from the center to let me know that another Mama had been sent over from the clinic! She had come in for her 40 week appointment and been found to have extremely high blood pressure and was transferred to a physician. I spent several hours at the hospital going between the two families, answering questions and offering support.

Eventually, I made it back to the center. (Both of the hospital mama's had been settled in.) I very quickly ate some food, as my last food had been that long ago Starbucks treat! Then I went over to the clinic to help with the end of the day. Very glamorous stuff like taking out trash, doing laundry and cleaning speculum's. I started getting phone calls from two other Mama's, both having their first babes. They would be coming in sometime, but not quite yet. I decided to try and leave the center for a bit. A friend of mine was having a "journal club", which means a bunch of nurses getting together and reviewing an article from a medical journal. I really wanted to go and visit with friends I haven't seen in months...so I went for it. It was a nice break and I was able to stay for a little while before heading back to the center.....

Kelly, was one of the first time Mama's who had been in early labor and talking with me over the phone. It was time for her to come in. She arrived with her husband and doula around 9pm. She was doing good, her baby sounded great...but her blood pressure was a touch high. Low enough to stay at the center, but high enough for me to need to monitor it closely. Her cervix was 5cm and we all got ready to work this baby out. Kelly worked very hard, spent time in the pool, in the bed and walking the hall. A few hours later she was 7cm, but her blood pressure had gone up just a touch more. I decided that we would need to re-check her blood pressure in 2 hours. Over those 2 hours, Kelly worked hard, she had some difficult stretches but we were able to talk her through them. Unfortunately, when we re-checked her blood pressure the third time it was very high and it warranted a transfer to the hospital. Now we had 3 Mama's over there! Argh!

Just before Kelly had to go to the hospital, the other first time Mama I had been talking with had come in! Nicole came in did not appear to be in labor, she was so calm. Initially, I felt bad for having them come in when it looked like they would need to go back home. However, as birth is so humbling, I was proven very wrong. Nicole was 7cm dilated! After I checked her cervix she literally, rolled over on to her side, in bed, pulled the covers up and went to sleep! About an hour later, she opened her eyes and asked if she could get in the pool. I said "yes" and asked if she was still having contractions, to which she replied "sure". She stepped into the pool, rested her head on her arms on the pool side and.....feel asleep! Again, some time later she opened her eyes and said she needed to go to the bathroom and that she was hot in the pool and wanted to lay down again. Sure thing! Once again, curled up on her side, appearing to be asleep....Nicole started grunting every couple minutes. I asked her if I could check her cervix and she was 9cm! I asked her to wait just a bit to really start pushing and she said "ok" and went back to sleep. Then, 15 minutes later, she opened her eyes and said, "I really want to start pushing and do you have a birth stool?" Wow! We set up the birth stool and 14 minutes later Nicole had a pink little baby boy in her arms! Amazing, amazing!......

Then it was 6am and time for me to go home. What a strange, hectic, wonderful shift! Of the many things that pregnancy and labor teaches me, one is to never, ever take anything for granted or to make assumptions. It seems that the more I learn...the less I know....

P.S. The 3 Mama's at the hospital all had vaginal births and healthy babes....

a day in the life....#1

Recently, I have been at the center for several 24 hour shifts. We are always scheduled for 24 hours, but usually are not there for the whole time, thankfully. I am writing about these two in particular because they were very different and exemplify the diversity of labor and birth....

Phone rings at 5am...time to get in to the center...a Mama is cooking. I arrive to be with Beth (names are always changed ;)) and her husband who are having their third baby. She is sitting on the ball, leaning over the bed working with her body and her baby. One of the old midwife sayings is, "first babies are hard work, second babies come fast and third babies are a wild card"...or some variation of that. So, I was prepared for that wild card effect with Beth. While we were all supporting Beth, my phone rang. Another Mama, Christie, who is having her second baby calls in labor...actually it was her husband who was on the phone, which usually means we are serious. They arrive shortly after their call.

Now, I have 2 Mama's working on their babies. Christie and her husband had a lot of great support...both of their Mothers, sisters and friends...and they were in the smallest room. Beth and her husband were on the other side of the center, just the two of them in our biggest room. Between the nurse and myself, we were able to be with both women and things went smoothly...my big concern was that they would both their babies at the same time! Luckily, that was not the case....

Beth's beautiful babe arrived first. When it came time to push, she had a difficult time...she did not want to do it. She remembered pushing her other children out and said that this time it hurt more and felt different. So, I did a vaginal exam and found that her babe was a little asynclitic, meaning a little "crooked", so I had her stand at the bedside and use the birth stick to "hang" and stretch out her abdomen for several contractions and the baby was able to right himself. After that, we had to do some talking through it and some coaxing through it and some laughing through it but in the end, Beth decided it was time to meet her new little one. He was born so sweetly and started crying as soon as his head came out...even before his shoulders were born! After her last baby, Beth had some heavy bleeding, so I gave her a little shot of pitocin and she had very minimal bleeding. The three of them, tucked into bed, babe nursing wonderfully and finished their recovery.

Next up was Christie. She had quite the audience with all the family members and friends present, but it was perfect for her and they were all amazing. Somehow, despite the crowd it didn't feel like a 'show' at all. She was in the pool and laboring beautifully. She started pushing on her own and soon was crowning. The baby's head emerged, but then stopped coming...so we quickly got Christie out of the pool and to the bed....all the movement was good because then her babe came right out. Christie had also had a lot of bleeding with her last babe so she got some pitocin as well and also hardly bleed. Christie and her husband are both brunettes, their oldest daughter is a cute little red head, so we were all curious about this new little girl's hair.....and it is red as well! They too, tucked into bed with a sweet nursing baby and finished their recovery.

Shortly after Christie's birth, another Mama and her family came to the center. Amy was a first time Mom and working hard, but well with her labor. She also had a large support network with her...multiple sisters (with their husbands and children), her mother and father. So, at this point the center seems to be busting at the seams...all three birth rooms full and two large family groups....somehow it worked out well. Then, a couple hours later, I get a phone call from another first time Mom, Jill. She is in labor and almost ready to head in! The birthday juices were flowing that day! Beth is almost ready to go home, so we set up our overflow recovery room and set her up there. Then we very quickly clean the room she had birthed in to get ready for Jill. Whew...a whirlwind of activity...such is birth!

So, eventually, Beth and Christie and their families all headed home...with a new addition each of course. The two first time mama's, Amy and Jill, remained to work on their little ones. As is normal, they both had some hard work to do. Again, between the nurse and myself we were able to be with each of them and offer support and guidance.

Jill's birth dance progressed beautifully. She spent most of her time in the birth pool and it was a joy to be present with her and her husband. They are funny, sweet people who worked so well together. They have been together for a long time and this pregnancy was a long time coming and you could tell they had such a great foundation of partnership. Jill welcomed her 8# cuddly, sweet baby girl to the world while squatting in the birth pool. We helped her to the bed, and the three of them all tucked in with a nursing little one and recovered wonderfully!

Amy's birth dance was more difficult and slow. She was an amazingly strong lady who worked so passionately for her baby. Her husband and family were wonderful and supported her through the whole process. Unfortunately, her labor just got stuck...we did multiple position changes and walking mixed with resting, herbs to encourage things and just could not move past the 7cm mark. After 16 hours at the center (and many hours before that at home) and a Mama who was exhausted we had to make the decision to transfer to the hospital. These situations are so hard and emotional for everyone involved. After several more hours at the hospital Amy and her husband were blessed with a healthy baby born via cesarean section.

So, if that seems like a jam packed, exciting and exhausting shift.....that's because it was! At the end, even though I was so tired, I was also so thankful for what I do. Ultimately, I feel blessed to be able to join these families during this most intimate event and to help support them through the transition.