a gift

Two weeks ago today, I was called to a birth.  I had been called to attend the same labouring mama three days before that, and soon after she arrived at the birth center that evening, her contractions spaced out.  We tried some of our midwife 'tricks' to get things going again, but it just wasn't the day, so she got some sleep and we sent her home the next morning.  She and her partner left most of their belongings at the birth center -- candles, fresh gardenias floating in a bowl of water, herbal tinctures, iPod dock, baby bag, etc -- fully expecting to be back later that day when labour really kicked in.  Well, her baby must have wanted to her to get plenty of good food and rest before the birth, and to exercise a great deal of patience!  Two nights and days later, we re-assembled at the birth center, and this time things were really cruising.  We filled up the tub and she and the baby's papa got into it.  Not long after that, she entered transition and a Native American song rose up from her and filled the air. She chanted like that through three or four long, deep, powerful contractions.  The atmosphere of the room was magical, and I had goosebumps.  Shortly afterward, we decided it was time to call the baby's two grandmothers into the birthing room (they had wanted to bear witness).

Slowly, a fuzzy head began to emerge into the water.  We performed our usual visual check of the baby's scalp colour -- usually, we do not touch the baby at all under the water as it is being born, since this may stimulate the baby to breathe (and aspirate water) before being lifted up into the air.  [And I should mention, since I am often asked about this: a baby will not 'drown' during a water birth -- it has a 'diving' reflex that closes the glottis and prevents the baby from taking a breath until its face comes into contact with room air, which is usually cooler than the water.]  So we usually know from observing scalp color, restitution, movement, extension of the neck, etc, that the baby is doing fine as we wait for the body to emerge completely.  We saw perfect restitution to the mama's left thigh, and a pale pink scalp.  Our mama said that she didn't feel another contraction coming yet, so we waited a little longer - no need to worry at this point, sometimes it just takes a few minutes.  There is no risk to the baby, so long as the mama keeps her yoni (and thus the baby's head) under the water, and doesn't rear up and then 'dunk' the baby's head in again, after baby has already taken a breath.

Another minute went by, still no urge.  I wasn't thinking dystocia, since there was no turtling of the head, and the scalp wasn't blue or growing darker.  Instead, my preceptor and I thought, perhaps the cord was holding things up. She put the camera down (she had been taking some amazing birth photos) and told the mama, push anyway, even if there's no contraction.  She did; nothing happened.  We got her into 'running start,' paying close attention to keeping her yoni under the water as she shifted into position.  She pushed again, and a limp, pale body came out.  I instinctively reached back for the O2 tank (we always have two; one is hooked up to an ambu-bag and the other connects to an adult O2 mask for the mama, with the option of connecting an infant O2 mask for free-flow if needed).  My preceptor grabbed the baby and found a tight nuchal cord with another tangle of cord across her torso.  Papa wanted to grab the baby, and I heard my preceptor saying, "Wait, wait!" as she unwrapped the cord.  The baby was being stimulated the whole time in the usual way -- rubbed along her back, flicked on the soles of her feet, suctioned repeatedly with the bulb syringe, being talked to by her parents and us: Come on, baby, please.

Somehow, this floppy little body was moved to me, and laid out on a towel on the ledge next to the birth tub. The cord was still connected to the placenta, so mama intuitively 'swam' towards us to give it some slack.  I put the ambu-bag over the baby's nose and mouth and gave her two puffs.  My field of vision was completely restricted to this three-foot circle immediately in front of me.  I couldn't make out people's faces; I had no sense of time (or rather, time slowed completely down); all I could see was the baby's face and my ambu-bag.  I didn't get a good seal the first time, so I tried again, with an open airway, watching for chest movement.  There wasn't any.  Somehow the breaths weren't getting through.  Her cord was pulsing the whole time, 140s.  (This is why I don't understand the practice, in hospitals, of immediately clamping and cutting the cord of a compromised baby and then whisking it over to the 'resuscitaire' to be worked on.  An intact cord is the baby's lifeline, keeping the vital organs perfused and protecting them from damage during the time that it takes for the baby to breathe on its own.  It is insane to cut it prematurely.)

My preceptor suctioned again, this time more vigorously.  One new midwifery student behind me was charting, and forgot to call time (normally, during a resuscitation, one person is responsible for letting the primary midwives know how much time has elapsed - 30 seconds, 60 seconds, etc).  Another new student was looking on, holding a resus board in her hands -- I didn't know about any of this until afterward, and next time, that student knows to be more assertive and to shove the board into our field of vision.  It was the first neonatal resuscitation she'd ever witnessed.  It had been about 30 seconds so far, and my preceptor looked behind her and said, "Call the EMTs, now."  (It is protocol to do this.)  One of the grandmas behind me said, "My husband is a physician, should I call him now?"  I made a half-turn to turn the dial up on my O2 regulator, and as I did so, I said to her, "No. We've got this."  I will admit here that what was going through my mind was, "Just let us do our job, for God's sake!"  I really could understand why she was so afraid -- I know it must have looked horrifying to her, and it was her grandchild, after all -- but I felt frustrated that the grandmas were watching this all unfold with pure terror.  I didn't want anyone to bring fear into that environment -- it wasn't going to help us not to have faith, or to be anything but calm.  Right or wrong, that was how I felt in that moment.  Two more puffs from my bag, a pulsing cord, no indication for chest compressions yet.  I watched her chest wall rise slightly with the puffs, but there was still no response.  My preceptor looked at me, determined, and put her mouth over the baby's face to give her a breath.  No response.  More mouth-to-mouth, nothing.  Then, she started squirming the tiniest bit.  I saw her mouth opening, eyelids wrinkling, a grimace.  Still no visible breaths though.  I lifted her cold little chin again, got a good seal, and gave her another puff.  Through the transparent plastic of my mask, I saw something I will never forget.  Her mouth opened wide, like an enormous yawn, and a second later she let out a magnificent yell.  It was so loud!  Her body started pinking up, and my preceptor said, call the EMTs off, we don't need them.

We handed her over to her mama, and the tearful grandmas behind us embraced each other, saying, "That was so scary!"  Lusty cries filled the room, and the parents welcomed their tiny girl with cooing and smiles.  Her face looked blue to me, so I put her on some free-flow O2.  After a couple minutes of that, I realized that her face was blue because she had been bruised during birth, not because she wasn't oxygenated.  So we discontinued the O2 and let the family bond in peace for a short while.

A little later, the placenta came out fine, with minimal bleeding.  Intact perineum, only two little splits with no need to suture.  The baby nursed within an hour, and looked like she'd been doing it for months already.  She was 9lb 4.5oz; cute as a button, and so mellow, but when I performed her newborn exam, she yelled in protest at the intrusion.  I told her parents she was a really feisty one, and we got her to calm down by getting papa to play with her hands.  I found a couple little bruises on her scapula, but otherwise she appeared unharmed, and had transitioned amazingly well.  Within no time at all, I could hear that she'd cleared her lungs completely -- beautifully crisp breaths through my stethoscope.  The bruising on her face was already clearing up by the time we discharged the family that night.  It confirmed to me that babies are so incredibly resilient.

With the family tucked up in bed, and the grandmas making tea, the midwives convened in our upstairs family room to hug and debrief.  I am going to get the new students together soon to run through some neonatal resus drills with them, for everyone's benefit -- mine included.  I was humbled by the experience, mostly because it just wasn't on our 'radar' at all to have a compromised baby.  Usually, our antennae prick up when we see or feel certain things, and I can tell that my preceptor is making extra-sure that we have all the haemorrhage meds lined up, or that the ambu-bag is really working (even though we check it before every birth), or that whatever else we may need is really within reach.  But this time, and perhaps because the birth right before this one was perfect in every way, we were taken by surprise.  I was amazed, in myself, at how my skills kicked in and I stayed calm. Even though I felt that I was fumbling in the raw moment, when I replayed the scene afterward I was proud of how methodical I was, and how I trusted deep inside that everything would be all right.  I know that sometimes it isn't all right, and bad things happen -- that's how life is.  But this time, well, she breathed.

Thank you, Universe.

birth day indeed

Yesterday was my birthday. I'm 28.  I had no idea that my twenties would fly by the way they have... the whole decade has been an apprenticeship, in something or other!  The best birthday gift I received was a love letter from my husband.

Fittingly, I came home from a birth yesterday at about 11am.  It was a sweet, perfect, glorious birth.  I had received a call from my preceptor the morning before (Feb 24th), when I was two hours' drive north of the birth centre where I work. I was getting my paperwork/biometrics sorted out with US Customs and Immigration, since I am now married to an American.  My preceptor told me we had a mama who looked like she was getting into a really nice labour pattern, and that I should come straight to the birth centre when I returned from my USCIS errand.  I did, and by 4pm, the mama (G4P2) was fully in transition, shaking, quivering her bottom lip, throwing up her egg-and-toast breakfast - in other words, doing some really hard work. The baby's papa was naked in the tub with her, and he was the most amazing birth doula I had ever seen. She was getting sleepy in the warm water of the tub, and it was making her lose focus as it came time to push. She said her urge to push wasn't really overwhelming (even though I knew she was almost complete, if not already 10cm).  She got out of the tub on our suggestion, and we dried her off and helped her get into LSL position in bed, with a chux-covered pillow between her legs to help keep her pelvis open.

She lay there for about twenty minutes and I suggested to check her (which I normally do not do) - only because her urge to push wasn't quite there and she told me she didn't really know where to push towards or how much force to apply.  She said that when she did push, it didn't feel good.  (Note: she'd had an epidural for each of her two previous births.)  That made me think she might have an anterior lip.  She was doing incredible work, breathing and moaning softly through each of her contractions, and between the next set I checked her gently and found the lip.  Her cervix was buttery and soft, baby's head +1 station, so we figured it was best to hold the lip back for a few contractions and see if she'd push the baby's head right past it and out.  Indeed, within 3 contractions, the lip had completely melted away and baby was almost crowning.  So, we called the mama's eldest daughter (age 15) into the room and I helped get papa into position for catching his own baby, which he had really wanted to do.  The mama was propped up with some pillows, and she said it really felt good to push now. A gorgeous, round head emerged with her next great effort, and the head breathed and gurgled immediately!  I nudged some chux underneath his chin, against mama's perineum, to keep him from suffocating in the fluid (he was completely OA). He restituted and I told papa, just gently put your hands on either side of his head, no need to tug, his body will come out with the next contraction and your hands will be supporting him.  He slid out, and papa held him up in his hands.  We all heard the baby's lusty cries right away. I gently swabbed away the mucus from his mouth and nose with some gauze (we avoid bulb syringes as much as we can around here - they're pretty horrifying, especially if your face is only about twice the size of the bulb, and a gloved hand is drilling a hard plastic probe deep into your tiny nostils and heretofore-unprodded mouth). He pinked up, yelled, and we all greeted him with expressions of love and delight.

He was handed immediately over to mama, who cuddled him with glee.  I helped her deliver her placenta with only the tiniest, slightest bit of cord traction, 350cc total EBL (that's all!).  We inspected it together, and papa was in awe - he took pictures of the tree of vessels on the fetal side, and asked me all kinds of questions. Then, the placenta was whisked away to be encapsulated for mama to take as her 'happy medicine' over the first few weeks postpartum.  I examined her yoni - no tears, just two tiny splits on the labia and a single small skid mark on the perineum.  I said to her, if I didn't have this bloody glove on right now, I would high-five you!  She laughed and cheered and kissed her baby.  He was a champ, and latched on within 40 minutes of his birth. He nursed for a little, and then lost interest, so I grabbed my opportunity for the newborn exam.  I got papa to talk to him and cuddle him throughout, but he still cried for the first part of the exam until I figured out that if I jiggled his tummy gently with my hand, he would stop, and look at me intently. 8lb 3oz, 19 inches long. Cute, mellow, perfect - not a single thing odd or untoward about him. So with that done, he went back to the warm envelopment of his mother.  I waited to administer his eye ointment (which his parents wanted him to get) until he'd had a good, long nursing session. I think it's better if the baby can see mama's face clearly while forming those early attachments. He nursed for 45 minutes, and he got his vit K and erythromycin while in her arms.  So much gentler that way!

We talked through all the postpartum and newborn stuff; what to expect re. bleeding, poop/pee, jaundice, nursing on demand, etc. The parents were awesome; we had a sweet connection and I felt that they trusted me, which is the best compliment I could receive. When they said they were so glad I was there, I said, you know, you could've done this without any of the birth team here - this baby was going to come out just fine!  And now you can say, you did it yourself, on your own steam, no medication, just love and faith and mama strength.  She smiled at me triumphantly.

I stayed at the birth centre all night as the weather had been freezing all week, and they lived some distance away. We all figured the roads would be terribly icy and it'd be best if they stayed overnight and got some good rest, too.  I checked in on them every so often for vitals, etc, and all was well. They bundled him up in his car seat in the morning and he looked so beautiful, all sleepy and tiny and content.

What a great Birth Day!

I'm Back...!

Back to the birth centre today! I'm back to full-time work as an 'advanced midwifery student' (how my preceptor describes me to clients), and back to being on call full-time for births between now and the end of July. It was a good day; not too busy, two third-trimester prenatal appointments, and two postpartum visits. I handled it all with ease and completed my charting long before day's end.  It feels good to be back, although I admit it's a little terrifying... as I take on more responsibility as midwife, I must face my 'demons' and try to remember why I wanted to do this in the first place. As a good friend of mine would remind me: Remember, that what you have now was once among the things you only dreamed of...

Count on more regular blog updates from now on, and also - once I get to it - a couple huge 'review' posts to fill in my blogging gap since December 2008. <gulp>