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.
