A bruise on the side of the baby’s head confirmed that he had been in an acyclic position, meaning his head was turned sideways, his ear almost touching his shoulder on his journey down to being born, which made it difficult to mold and descend properly. And now we knew his cord was short, too. We were just very grateful it didn’t break before he was out, which would have been catastrophic. It had taken all that time to stretch so he could be born. It never ceases to amaze me how nature accommodates such exceptions to the rules.
The combination of all of these factors caused Jessica to sustain a fourth-degree tear, which caused some complications later on, though she was able to find help for it. Tears are graded by the depth of the tear into skin and muscle. First-degree vaginal tears are the least severe, involving only the skin around the vaginal opening and the birth canal. Although there might be some mild burning or stinging with urination, first-degree tears aren’t severely painful and heal on their own within a few weeks, often without stitching.
Second-degree vaginal tears involve vaginal tissue and the perineal muscles—the muscles between the vagina and anus that help support the uterus, bladder and rectum. Second-degree tears typically require stitches and heal within a few weeks.
Third-degree vaginal tears involve the vaginal tissues, perineal muscles, and the muscle that surrounds the anus (anal sphincter). These tears sometimes require repair in an operating room, rather than the delivery room, and might take months to heal. Complications such as fecal incontinence and painful intercourse are possible.
Fourth-degree vaginal tears are the most severe. They involve the perineal muscles and anal sphincter as well as the tissue lining the rectum. Those who experience complications from severe vaginal tears are often referred to a urogynecologist, colorectal surgeon, or other specialist.
I saw Jessica and Taran a few months later. He was so amazingly strong, self-assured and inquisitive—a real “in arms” baby. The difference is very obvious to me when a baby’s needs have been met during his early weeks and months and he has not been forced to “learn” to put himself to sleep or not been picked up when he needs that, thus spending more time than not “in arms.” And Jessica, having herself been on this bizarre, wonderful, outrageous, momentous journey of birth, is truly a doula, able to put herself into another mother’s sandals, socks, or bare feet at their birth.
Taran, a real in-arms baby!
“We are the mothers, after all, the ones who speak the cultural narrative and teach it through, well, old wives’ tales, which is to say, the ancient, subversive, and immediate mother tongue, the language of metaphor and myth.”
~Ellen McLaughlin
Chapter 21: Four Memorable Births
Four births from a recent year stick out in my mind. All of the mothers had written birth plans and educated themselves about natural birth. None were easy. Interventions were used at three of the four births. I continue to wonder what I could have done differently as a doula. The most interesting factor, though, was the mothers’ perceptions of their births. They were decidedly different. One felt utterly traumatized. One was deeply disappointed and felt she had “failed.” The third mother felt good about her choices and grateful her babies were doing so well. The last mother was happy it was over and did not feel any of the negative emotions the first two did. All were first babies. So what was the difference?
Birth #1
Hadassah and her husband, Orthodox Jews, had long looked forward to having their first baby and absorbed all the information they could from the Internet, books, classes, and friends. Her labor at a free-standing clinic went very well until her water broke at around seven centimeters. There was meconium. Lots of it. Her midwife was not comfortable continuing the birth there and advised a transfer to a nearby hospital. As her doula, I rode in the car with Hadassah to the hospital, coaching her during the rushes, trying to maintain some of the same calm we had enjoyed working together until then.
The clinic had worked with this hospital before and we felt very welcomed when we arrived. The staff assessed that she was indeed progressing nicely and because the baby’s heart tones still sounded good, the obstetrician suggested that going for a vaginal delivery still seemed fine to him. I stayed by her side throughout the birth and she delivered a beautiful little girl later that evening. I was glad she had not needed a C-section and that her baby did not have to go to the NICU. So why did she feel that this birth was the most traumatic event of her life and she needed to go through intense therapy for the next eight months? In her words she felt “humiliated, vulnerable, exposed, degraded, and in shock.” Hadassah felt the nurses didn’t respect her because they chatted about “insignificant things” during her labor. She was also upset that her midwife withdrew all of her support the moment they arrived at the hospital, after having built a relationship with her over the previous seven months, and that having a male obstetrician was an “unfeeling” choice the hospital dumped upon her.
Birth #2
Tessa, a yoga teacher, had eaten extremely well, exercised daily, and seemed to have an amazing attitude toward natural birth. Her labor was long—two days of prodromal labor, or early labor, had worn her out. Instead of sleeping when she could, she and her husband had hiked the neighborhood the whole first night, trying to encourage the real thing. They checked into the clinic in the morning but little progress had occurred in her labor. At that point her midwife suggested they hire a doula to work with them at home until she was in active, effective labor. That is when I was called.
I had not met this couple before but felt right at home when I went to their house. I explained that it seemed the contractions were petering out because, like a car that won’t work unless it is refueled, her body was telling her it needed rest and food. I suggested she rest, which she didn’t object to this time, while I cooked up a pile of whole grain pancakes and served them with yogurt and honey. She ate the entire plateful and then they both slept for six hours. A huge rush woke Tessa up. When they were five minutes apart we went back to the birth center. She labored in the tub for several more hours but seemed to get stalled at eight centimeters. Her midwife tried having her climb stairs, squat, walk, and do lunges but nothing was helping her baby move down any further. By evening she was again exhausted and very discouraged. The last ultrasound had suggested her baby was about eight pounds. Tessa was six feet tall and seemed to have plenty of room.
The couple finally decided to transfer to the hospital. Tessa wanted something for pain at this point and asked me to come with them. The baby sounded great and the OB felt she just needed more time. Tessa opted for an epidural, which gave her much-welcomed relief. As she was able to relax, she became fully dilated. She started pushing but after an hour, the baby still felt very high up in the birth canal. The doctor tried massaging the posterior wall internally hoping to stretch it further and help the baby along. It seemed to help, so for the next hour he kept his hands where he could direct her pushing from inside. She pushed until the head was finally crowning but the doctor explained that what we were seeing was “caput,” or the baby’s swollen scalp, which had also stretched, but that the bones of the baby’s head were still molding and had a ways to go yet.
I had never seen someone push so hard for so long. I wondered what we could have done differently or better. I would have my answers when he was finally born: he weighed eleven pounds, two ounces, almost three pounds bigger than anyone guessed. He also had the shortest umbilical cord I had ever seen. It took that long to stretch without detaching from the placenta, which would have proven fatal for this baby. So nature did know that what was needed was time, more than most births. Much more. Tessa felt afterward that she had not prepared herself fully for the rigors of childbirth. She felt keenly disappointed and robbed of what she thought should have been an ecstatic experience. She felt cheated and regretted having “failed” by asking for the epidural. It should have been different, in
her mind at least, meaning better than it had been, and she asked me if she would regret these choices for the rest of her life. She wanted to know if she could have somehow been stronger or better prepared, still blaming herself. I did my best to tell her that this was the land of parenthood and that she had done what she needed to do to birth her baby, and that I was very proud of her. I think in her mind, though, she still thought she should have been stronger.
Birth #3
Amber couldn’t believe it when the technician at her first ultrasound congratulated her for being pregnant with twins. But the euphoria completely wore off when, toward the end of the pregnancy, she was put on bedrest for three of the longest weeks of her life. She read books, talked on the phone for hours, watched TV, ate and slept, then did it over and over until she went into labor one morning at almost thirty-seven weeks. I met her at the hospital within an hour.
She spent the day walking, resting, sitting on a birth ball, in the tub, and munching on snacks. The hospital staff was amazingly open to intermittent rather than continuous monitoring and allowed her to eat and drink. They left us by ourselves for most of the day. Things were going really well until about seven centimeters, when Baby B’s heart tones became a concern.
Twins are labeled A and B, with A engaged or lower in the pelvis and most likely to be born first. Surprisingly, the obstetrician didn’t rush in to intervene but waited and watched for enough of a change that he could be reassured. Other factors, none critical by themselves but enough in combination to raise concerns, included the fact that all of a sudden the contractions were spacing themselves out from five minutes apart to ten or fifteen minutes apart. This, along with Amber’s slowly rising blood pressure, led the doctor to call together the birth team and the parents to rethink their plan.
Although Amber had written a birth plan and had educated herself extensively about natural birth and the possible interventions, she was amazingly relaxed about having to switch gears. She asked me what I thought and if I had any suggestions. I told her once again (this had come up several times in our prenatal meetings) that I would not make any decisions for them, but I could give information to help them figure out what would be best for their family. I told her that she could again take a wait-and-see approach and ask for more time, or go with a Cesarean section right then, which is what they opted for. Dad and I were given bunny suits to put on over our clothes along with sterile hats, masks, and booties to cover our shoes. Amber had been given an epidural by the time we joined her in the operating room.
I stayed by her head, where I could narrate what was happening step by step. Dad held her hand and sat in his assigned place trying to take it all in. Within ten minutes I was explaining that she would feel quite a bit of pressure or pushing and tugging and that the first baby would soon be out. Within another minute, Baby A was crying and being rubbed down on a nearby warmer.
Within three minutes Baby B was also out and on his way to a second warmer. Two sets of nurses trained in neonatal resuscitation were standing by ready to assist either or both babies to breathe if needed, but they were both doing really well on their own and were given good Apgar scores. All of a sudden two very healthy babies were both crying while they were being wrapped up to make the trip over to meet their mom.
Dad was given a baby on each arm to hold where Amber could see and touch them. It was beautiful to watch this little family of two that had suddenly doubled. They asked me to take pictures so I tried to get lots of different angles without stepping on a nurse’s toes or bumping into one of the anesthesiologists. Finally we were all transferred to the recovery room, where Amber could nurse their babies. Vincent and Victor were safely here!
Although she had a long recovery ahead of her, Amber was happy and grateful for the way things went with their birth. She told me simply, “It was what it was” and everyone was here and healthy. She knew she had done everything she could.
Birth #4
When I received the referral for a first-time mom newly arrived from Ethiopia, I was excited. I met with Eleni every week leading up to her birth. We covered all of the material in the childbirth education series during our prenatal visits, which we squeezed in between her busy work and school schedules. She couldn’t go to a regular class offered at one of the local hospitals because she had to take the bus to get there and did not want to do that at night. Her husband worked the night shift so he couldn’t accompany her. So we met and watched teaching videos and addressed all of her questions during our visits together.
She had a difficult pregnancy, complicated by an infection contracted before she arrived in the U.S. and then another rare event affecting her fluid retention. Her OB carefully monitored both her health and the baby’s during this pregnancy and felt that a natural birth was still possible as she neared her fortieth week. Both conditions would be treated after she gave birth but could only be observed and followed until then. She was still not showing any signs of going into labor at forty-one weeks but everything looked okay, though her OB was guarded about waiting much longer. A few days later Eleni called me from her OB appointment to tell me that she was being advised to go in that same day and have her labor induced. We would meet at the hospital later that afternoon.
When I arrived the family was still waiting for an Amharic translator. The OB doctor wanted to explain their options for starting labor and wanted to be sure the couple understood everything. That done, we settled in for a long day. The prostaglandin, a cream that they used, worked quite well to ripen her cervix and within two hours we had contractions, light ones but increasing, and she began dilating. We kept waiting for active labor to begin—the point where she would be four centimeters and have good, regular contractions—but instead of the ideal one centimeter per hour, we were going along at about one centimeter every three or four hours. Eleni’s OB seemed unconcerned and told us that as long as the baby sounded good, and he did, we didn’t need to rush things at all. This was a far cry from the “old days” that I remember, where they simply kept adding intervention after intervention to make it “work” within some magical time frame, no matter what, and almost without realizing it slid into what we call “the domino effect.” A mom would get Pitocin to ramp up labor, which caused more pain and a request for more drugs that in turn affected the baby so different drugs were tried. Then they would break the water to speed things up, and the baby would react badly at some point to everything that was now on board and before she knew it the mother was being wheeled into the OR for a C-section. That is the “domino effect.”
Eleni ate and drank, rested, sat on a birth ball, walked the hall, and rested some more over the next fifteen hours. At one point the doctors suggested trying Pitocin if things slowed down any more, but put off that idea for a few hours. By morning, they asked if the couple was okay with that or what they would like to do. We talked about it and Eleni asked if she could get something to help her rest for a while and see if the rushes would pick up on their own if she was less exhausted. We had discussed some of these options during our prenatal appointments and as Eleni was still wishing for this birth to be as natural as possible, the doctor agreed. We turned off the lights, closed the door, and Mom, Dad, and I all got in a two- to three-hour nap, which felt great.
We woke up when her water broke on its own (called spontaneous rupture of membranes) toward the morning of the second day. The water was clear and her baby girl still had an amazingly good heart rate when they checked her. Still at a rate of about one centimeter every three or four hours, Eleni slowly progressed. It was enough progress, and no regression, that the doctors—there were now three female doctors checking in with us—didn’t feel anything had to be done, but said that they could offer a few ideas if Eleni was interested in speeding things up. I assured her that this was up to her but that her baby sounded very good. She continued to eat and rested when she got tired of walking or being on the birth ball. She spent the
next few hours in the candle-lit tub room, dozing as I slowly dribbled a steady trickle of warm water over her belly. She was at five centimeters, still considered progress.
When the rushes started getting stronger, Eleni told me she was scared. She didn’t know what to do next. She didn’t know if she would be too exhausted to push later. She didn’t know how much more she could stand. I explained again that this was the longest and the hardest part of labor, that going into transition is the end of this stage and that she was doing wonderfully. I told her that her baby still sounded really great and that we would help her with each rush as it came. I reminded her that she only had to get through one rush at a time.
She closed her eyes and lay back down in the water. I was calculating in my head that at this rate we could be doing this for eight or nine more hours.
I thought maybe imagery would help so I said, “Sweetheart, look up at the ceiling. See that big black circle (the exam lamp)? That is how big you need to be. You will open like a flower, petal by petal. You won’t break. You have lots of room and your baby isn’t huge. She is probably six or seven pounds, just right for you.
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