Push It!

I am sitting here at my husband's bedside and am so thankful, among other things, for a laptop and free WiFi! Phoenix Baptist is a wonderful hospital but I have been told there is no WiFi available. I would really be insane by now (we've been here for 6 days now) with no internet! I am taking advantage of this time (and believe me, I have a LOT of time on my hands at the moment) to do some blogging and catch up on my regular blogs I like to read.

I was over on At Your Cervix when I found a link to this wonderful blog carnival on pushing....a a baby out that is. Amy Romano is hosting this carnival on Science and Sensibility blog. I very much enjoyed the post and think you will too.

The Fifth Healthy Birth Blog Carnival: Push it real good!

YouTube Changing Birth Culture?

This is an interesting blog post by Amy Romano CNM. She discusses how YouTube could be a potential change agent for birth culture. Cool! A use for technology that is positive and helpful :)

I'll admit....in my desire to share what normal birth looks like, I have 'made' my daughters watch several YouTube birth videos. My 6-year-old, Liberty, finds them absolutely fascinating. She begs to come to work with me and see someone have a baby. I told her maybe someday. My 9-year-old, Daja, is not so interested. But she's also very much a tomboy and shies away from 'female things'. She has been to work with me and watched a birth. She did ok but I don't think she found it as awesome as I always do! She was a little green when the placenta came out. I had hoped to let her touch it (with gloves on, of course) but ended up sending her out of the room. :)

T's Birth

I had been seeing T all throughout this pregnancy as well as her first pregnancy. A student midwife and I had caught the baby last time. I was looking forward to catching this baby myself! T was kind enough to go into labor during my weekend on call :)

T is an herbalist and does not believe in taking any man-made medicines with the exception of life-saving. Her first labor and birth was done naturally and this one would be the same.

I had just left the hospital to go meet my mother to try and do some christmas shopping when T called me. She told me she had been contracting through the night and the contractions were pretty intense. They were also about every 6 minutes apart now. Her water had broke earlier that morning. I told her it sounded like she needed to come on in.

When she arrived, I was a little nervous because she looked very comfortable, even when having a contraction. She would breathe through the contraction but there were no other signs that she was having one....meaning her body and face were very relaxed. I was thinking that she might be very early in the labor. But I also know that everyone handles pain differently.

We got her settled in her room, got a quick strip of the baby, who looked great. Then we got her in the tub. Her cervix was dilated 5cms at this point! Woohoo! T and I sat in the bathroom for the remainder of her labor. Well, she was in the tub while I sat on a stool beside the tub :) T was amazingly relaxed and seemed to enjoy the tub. We talked about all kinds of things....from family to spirituality! I was worried that I was distracting her from her labor but she assured me that everything was fine. Her contractions eventually began to move closer together, until they were about 2-3 minutes apart. I was really enjoying watching her labor. I was able to tell when she moved into transition...not because she made more noise or anything, just because she stopped talking but still maintained a very relaxed appearance. I could tell that she was becoming more focused and drawing inward. She looked beautiful!

Eventually she told me that she could feel the baby moving down. I rechecked her while she was in the tub...she was 8-9cms now. However, I had a feeling that would be changing quickly. We waited a few more contractions until she felt like she needed to push. I rechecked her to find the baby at +2 station (+3 is crowning) and told her she was definitely ready! We moved her to the bed, where she made herself comfortable. She pushed when she needed to, focusing on her husband, who stood at the bedside. She was absolutely silent. She looked exactly how I would imagine a labor goddess to look :) She pushed with great control for about 6 minutes. She delivered another beautiful baby girl over an intact perineum approximately 2 hours and twenty minutes after arriving!

Congratulations T and I can't wait until the next one!!!!!!!

J's Birth

J was sent over from the office to the hospital for a NST (non-stress test) and to check the fluid around the baby as she was 41.2 weeks pregnant. The plan was for her to come in the next morning to have her water broke as a means of getting labor started. Her cervix was 4cms in the office that day with the baby's head quite low in the pelvis. Diane had called me to let me know she was coming. Diane would be on call the next day.

J had previously had epidurals with her other children. From what she told me, it sounded like she would get to transition then was offered an epidural, where her response was yes. Then she would deliver 30 minutes later. Her previous children were all caught by doctors. She very much wanted to do this natural.

When J arrived and was put on the monitor in triage, I was a little concerned. I didn't like how the baby's heart rate looked so opted to just keep her for the night. Well, I may have jumped the gun because once she came back to L&D, and was on the monitor, the baby looked fantastic. She was also contracting about every five minutes but feeling just a bit crampy with them. I asked her what she wanted to do...stay and break water tonight, stay and do nothing tonight, or go back home. Her and her husband had already made arrangements for their other children (a set of twins and a singleton) and they lived a fair ways away. She decided to stay.

We discussed breaking her water versus not, and she decided to have me check her first. Her husband wasn't there yet but would be in about an hour. She asked if breaking her water would cause her to deliver before he returned. I told "oh no, you won't go that fast!".

Famous last words.

She was 4-5/100/0 when I checked her so she opted to have her membranes ruptured. We even waited until after the nurses' shift change (maybe 20 minutes) before we did it. Once her water was broke, I asked her to walk a bit. She was also looking forward to getting in the tub and trying the birth ball. I went to do some paperwork and saw her walking a bit in the hallway. In hindsight, she looked a bit out of sorts, but at the time I didn't think too much of it.

A few minutes later she went back in the room and the nurse came and asked me if she could have something to eat as she was feeling light-headed. I went in to check on her and she was sitting on the edge of the bed. She told me this was what she didn't like about labor last time either...I suggested some protein as well as carbs. I told her I would be right back to check on her. I went to another patient's room to check in on her. While I was in there the nurse came and stuck her head in the door to tell me that J was asking for an epidural.

I was like "what???" She was doing fine when I had just been in there. So I tell the nurse not to do anything, I'm coming to check on her first. When I get to the room, she's still sitting on the edge of the bed. She tells me I can't do this. Then she grunts and bears down.

I'm thinking "what the heck?" I told J, let me check you before we make any decisions, you haven't tried the tub yet, and it sound slike you are getting close. She was spontaneously bearing down with each contraction. I checked her and she was 9 and a half cms! I said no epidural. She wanted to get in the tub so she squatted in the tub. I sat at her side holding her hand. I started worrying that her husband wasn't going to make it. I don't think she was in the tub more than 10 minutes when she started pushing again. She told me that the baby was coming. I checked and she was certainly correct - she was completely dilated and the baby was at a +2 station. I asked her if she could get out and maybe squat by the bed for delivery (we aren't supposed to do waterbirth although if she hadn't been able to get out, oh well). She was able to move over by a chair in the room. My thought was that she could lean on the chair and I would catch the baby from behind. Not quite how it worked out.

She squatted while I sat on the floor. She had one arm around my shoulders with her other hand on my leg for support. The nurse stood near by, not really sure what to do. She wanted to listen to the baby's heartbeat but I said not to worry about it, we could listen when the baby came out. I could not see what was going on as my head was crushed against J's chest. It was kinda funny :) I kept talking her through her contractions. She would talk completely normally in between contractions, asking what to do. I had one hand at her vagina, where I could feel the head crowning. She slowly and gently pushed the head out. It was such a thrill to not be able to see what I was doing but feel the head being born into my hand. We had a little trouble with the shoulders but nothing that wasn't remedied by me getting both hands involved. She gracefully pushed out the rest of her baby. I brought the baby up to her arms and the nurse threw a blanket over them. The baby was doing absolutely fine as was momma. We helped her move to the bed where she could rest while latching the baby on to the breast. Her husband walked in literally five minutes after the birth.

She pushed out her placenta just as gracefully. She had just a small perineal tear requiring no stitches.

Congrats J on a beautiful birth!

Birth Physiology by Michel Odent

One of our favorite birth advocates, Michel Odent, has some wonderful wisdom and knowledge to share...Read on!

Lylaine

BIRTH PHYSIOLOGY:
AN OVERVIEW

by Michel Odent

What are the basic needs of human mammals when they are giving birth? In spite of thousands of years of cultural interferences, it is possible today to rediscover such needs with the help of a small number of physiological concepts (Odent 2001).

BASIC MAMMALIAN NEEDS

Our current understanding of birth physiology is based on the adrenaline–oxytocin antagonism: when mammals release adrenaline they cannot release oxytocin. We use the word ‘adrenaline’ as a simplified way to refer to the ‘fight and flight system’. Such an antagonism has been understood for a long time and evaluated in relation to myometrial response (Zuspan 1962) and milk ejection response (Whittlestone 1954). The first data have been confirmed by clinical studies among humans (Lederman 1978). Today oxytocin is often presented as ‘the mirror image of adrenaline’. (Uvnas-Moberg 2003).

It is well known that mammals (including humans) release adrenaline in situations such as being scared, feeling observed, or being cold. We can therefore draw the preliminary conclusion that in order to give birth a woman needs to feel secure, without feeling observed, in a warm enough place.

Although the adrenaline-oxytocin antagonism is theoretically established, it is not well-digested knowledge. It disagrees with deep-rooted beliefs. It is still commonplace, in natural childbirth circles, to include recommendations based on the simplistic idea that walking and using the force of gravity will make labour easier. Finding these recommendations strange is not new. As early as 1833, William DeWees wrote that ‘the preposterous custom of obliging her (the labouring woman) to walk the floor with a view to increase the pains when tardy should be preremptorily forbidden’. Today scientific evidence tends to support De Wees’ point of view. Since the prerequisite for labour to establish itself properly is a low level of adrenaline, it is a good sign when a labouring woman does not feel the need to stand up and walk. During the first stage of an easy and fast birth, women are often passive, for example on all fours or lying down. To suggest any sort of muscular activity at that phase can be counter-productive, even cruel.

This belief that a woman in labour should walk can still influence medical circles as well. This is how we can explain the popularity of the term ‘walking epidural’ and also the publication of randomised controlled trials to evaluate the effect of walking on labour and delivery. Of course none of the studies could demonstrate any effect. It is significant that, in the most authoritative of these studies, 22% of the women who were assigned to walking stayed in bed.(Bloom 1998)
In natural childbirth circles, labouring women are also often compared with athletes who are advised to consume large amount of carbohydrates before starting extreme physical exertion, such as running a marathon. Authors of articles about nutrition during labour have suggested that we should learn from sports medicine. Many birth attendants are influenced by these comparisons and encourage women to eat food such as pasta at the onset of labour, and to drink something sweet when labour is established: ‘You need energy!’.

These ideas about nutrition are also in contradiction with our current understanding of the adrenaline-oxytocin antagonism. A low level of adrenaline and good progress in the first stage imply that the striated muscles are at rest. When a birth is as physiological as possible, the labouring woman has a tendency to be immobile during the first stage. When all the skeletal muscles are at rest, such as when the mother is lying on her side or is on all-fours, energy expended is insignificant, and the need for carbohydrates is minimal, insofar as glucose is the favourite fuel of skeletal muscles. The energy expenditure of the uterine muscle is insignificant. Smooth muscles are between 20 and 400 times more energy efficient than skeletal muscles. Furthermore they can easily use fatty acids (rather than glucose) as fuel. In practice there is no risk of fuel shortage for the smooth muscles. The observations by Paterson and colleagues are highly significant. They found that ketone levels were higher in women who had been starved for twelve hours before an elective caesarean under general anaesthesia than they were for women who had been in labour. This confirms that labouring women spend less energy than those who are only waiting for an operation without being in labour.

Comparing labouring women to marathon runners is misleading and potentially dangerous. The side effects of sugar during labour are well documented. There is evidence that when the mother has been given an infusion containing glucose, the risk of lactic acidosis in the fetus is increased and the intensity of jaundice in the neonate is greater (Kenepp et al 1982)..

These theoretical considerations are supported by what we can learn from observation. Mammals in general do not eat during the process of parturition. For several decades, either in a hospital or at home, I have learned from thousands of women who were neither encouraged nor discouraged to eat and drink in labour. Although there are always exceptions, it is possible to summarize several simple observations. The first point is that labour rarely starts when a pregnant woman is hungry. This makes sense since hunger tends to increase the level of catecholamines. Second, when labour is really well established, women do not feel the need to eat.

OVERCOMING THE SPECIFICALLY HUMAN HANDICAP

A specifically human handicap during the process of parturition is the huge development of the neocortex in our species. During the birth process (or during any sort of sexual experience) most inhibitions are related to neocortical activity. In general rational control of the procreative drives is a byproduct of human brain evolution.

The evolutionary process found a way of overcoming this vulnerability. Neocortical activity simply becomes reduced during the birth process. This had not been understood by the Pavlovian physiologists whose theories are, directly or indirectly, at the root of most current schools of ‘natural childbirth’. It is, on the other hand, easily interpreted by those who have the experience of undisturbed, unmanaged and “uncoached” births. When a woman is giving birth easily, without any interference, there is a time when she seems to cut herself off from our world. She becomes indifferent to what is happening around her. She tends to forget her plans and received ideas. She behaves in a way that would be considered unacceptable in the daily life of a civilized woman. When, for example, she dares to scream, or to swear, or to be impolite, it means that there is reduction in neocortical control. She can find herself in the most bizarre, unexpected, and often primitive, quadrupedal and typically mammalian postures. She seems to be “on another planet”. This reduction of neocortical activity is an essential aspect of birth physiology among humans. It implies that labouring women need to be protected against any sort of neocortical stimulation. We must remember the main stimulants of the human neocortex are, if we are to avoid such stimulations.

Language is a specifically human stimulant of the neocortex. When we communicate with language we process what we perceive with our neocortex. This implies, for example, that if there is a birth attendant, one of her main qualities is her capacity to keep a low profile and to remain silent, to avoid in particular asking precise questions. It will probably take a long time for people to realize that a birth attendant must remain as silent as possible. It is difficult to get rid of the after-effects of the Pavlovian theories. Velvovski and other Pavlovian theoreticians had understood the neocortical origins of inhibitions during human parturition. However, probably because they were not practitioners directly involved in childbirth, they ignored the reduction of neocortical control as an essential aspect of birth physiology in our species. They assumed that the practical objective should be to ‘recondition’ women in order to eliminate the inhibitions and to make childbirth painless. From their point of view labour pain is a conditioned reflex, and therefore cultural. Such theories lead to the concept of ‘verbal analgesia’. After visiting the Pavlovian theoreticians in Russia in 1951, Lamaze introduced their concepts in Western countries. This is how the birth attendants started to overuse language and became invasive guides, helpers and even ‘coaches’.

Light is another well-known stimulant of the human neocortex. Electroencephalographers know that the trace exploring neocortical activity is influenced by visual stimulation. We usually close the curtains and switch off the lights when we want to reduce the activity of our intellect in order to go to sleep. This implies that, from a physiological perspective, a dim light should in general facilitate the birth process. These are important considerations in the age of electricity, when we have the power to switch on a bright light simply by pressing a button. It is noticeable that as soon as a labouring woman is on ‘another planet’ she is spontaneously driven towards postures that tend to protect her against all sorts of visual stimulations. For example she may be on all fours, as if praying. Apart from reducing the back pain, this common posture (with many asymmetrical variants) has several positive effects, such as eliminating the main reason for fetal distress (no compression of the vena cava), influencing the process of rotation, and therefore minimizing the mechanical difficulties that characterize human parturition.

Feeling observed is a situation associated with neocortical stimulation. When we feel observed, we tend in return to observe ourselves and to correct our attitude. This is another way to interpret the importance of privacy (i.e. not to feel observed) as a basic need during labour. Understanding the need for privacy makes us anticipate, for example, that there is a difference between a midwife staying in front of a labouring woman and watching her, and another one sitting in a corner. It might also make us anticipate that devices that are perceived by the labouring woman as observing tools (such as a camera or an electronic fetal monitor) should be introduced with extreme caution in a birthing place. The surprise produced by the results of randomized controlled trials comparing the effects on statistics of electronic fetal monitoring versus intermittent auscultation is a symptom of a lack of understanding of birth physiology. It might have been anticipated that the only fact that a labouring woman knows that her body functions are continuously monitored tends to stimulate her neocortex. Stimulating the neocortex risks making the labour longer, more difficult, and therefore more dangerous so that more babies must be rescued via the abdominal route. Photos in books for the general public and videos shown in conferences constitute proof that the need for privacy is not understood by the natural childbirth movements: it is commonplace to see a woman in labour surrounded by several people watching her.

The perception of danger is another possible stimulant of the neocortex. Since in situations of danger it is an advantage to be alert and attentive, neocortical activity is an appropriate response. Analyzing such a situation is another way to consider the need to feel secure as basic during human parturition.

Understanding the solution the evolutionary process found in order to overcome the specifically human handicap in parturition appears today to be a necessary step towards rediscovering the basic needs of labouring women.

BASIC NEEDS DURING THE THIRD STAGE OF LABOUR

Provided there have been no major deviations from the physiological reference during the previous phases of labour, mother and baby share similar basic needs during the third stage. From a physiological perspective there is a key event between the birth of the baby and the delivery of the placenta. It is the high peak of oxytocin that human mothers have the capacity to release immediately after the birth, which is arguably the highest level of oxytocin a woman can reach during her whole life. (Nissen 1995) This peak of oxytocin is vital, since it is necessary for a safe and bloodless delivery of the placenta, and since oxytocin is the main component of the 'cocktail of love hormones' that is supposed to be released in the perinatal period.

Whatever the circumstances, a release of oxytocin is highly influenced by the environment. We must therefore look at the factors that can have a positive or negative effect at the beginning of the mother-newborn interaction. By mixing theoretical considerations and clinical observations we can identify two main groups of factors. At this phase of labour, the vulnerability of mothers to an inappropriate ambient temperature is well known. This is why shivering (a sign of adrenaline release) is a frequent physiological response to an insufficiently high room temperature. In fact, just after the birth of the baby, mothers never complain because the place is too hot, while nonverbally they often indicate that it is not warm enough. The concept of adrenaline-oxytocin antagonism, alongside clinical observation, must bring us to the conclusion that, as soon as the baby is born, the thermo-regulation of the mother must be at rest. In other words, maintaining an appropriate ambient temperature should be the first preoccupation.An undisturbed interaction between mother and newborn is another factor facilitating oxytocin release. During the third stage of labour an appropriate maternal hormonal balance is more easily obtained if, in an atmosphere of privacy, the mother can feel the skin-to-skin contact, can try to establish eye-to-eye contact, and can smell the odour of her baby…without any distractions. Eliminating any distractions is difficult: as soon as a baby is born, there is always an irrational need for activity around; there is always somebody who wants to do something or to say something. This need for activity has been ritualized in many societies. It is impossible to offer an exhaustive catalogue of all the possible ways to interfere with the mother-newborn intimacy. Let us imagine, for example, that a mother is still in such a state of consciousness that she has forgotten the rest of the world while discovering her baby; suddenly somebody appears with two clamps and a pair of scissors in order to cut the cord. This distraction is a dangerous interference with the physiological processes.

At the very time when we are starting to understand the importance of the third stage for the ‘development of the capacity to love’, we have to realize that this particular phase of labour has been dramatically disturbed by all cultural milieus via a great diversity of beliefs and rituals. Furthermore we have to realize that, in the age of the safe caesarean, this phase of labour can be purely and simply eliminated for the first time in the history of mankind.

References

**Bloom SL, McIntire DD et al (1998) Lack of effect of walking on labor and delivery. N Engl J Med; 339: 76-9
**Kenepp NB, Shelley WC et al (1982) Fetal and neonatal hazards of maternal hydration with 5% dextrose before caesarean section. Lancet ii:1150-52
**Lederman RP, Lederman E, Work B, McCann DS (1978) The relationship of maternal anxiety, plasma catecholamines, and plasma cortisol to progress in labor. Am J Obstet Gynecol 132(5):495-500
**Nissen E, Lilja G, Widstrom AM, Uvnas-Moberg K (1995) Elevation of oxytocin levels early post partum in women. Acta Obstet Gynecol Scand 74:530-3
**Odent M (2001) New reasons and new ways to study birth physiology. International Journal of Gynecology and Obstetrics 75:S39-S45
**Uvnas Moberg K (2003) The oxytocin factor. Da Capo Press. Cambridge MA

**Wittlestone WG (1954) The effect of adrenaline on the ejection response of the sow. J Endocrin 10:167-172
**Zuspan FP, Cibils LA. Pose SV(1962) Myometrial and cardiovascular responses to alterations in plasma epinephrine and norepinephrine. Am J Obstet Gynecol 84(7):841-851

A Day in the Life of a Midwife

Typically we do 24 hours of call at a time or a whole weekend, however there are occasional 12 hour call shifts also. I was on call for 12 hours recently...and it was very busy!

0700 Call starts - I'm in bed.

0745 The first page of the day from Labor & Delivery (L&D). Someone's water has broken - which is ok because she's supposed to be having a baby anyway.

0747 Get up and help the husband get the kids off to school. Avoid the whole raised-by-wolves-look by actually brushing the girls' hair.

0815 Think about getting dressed.

0816 Lay back down.

0820 Get up, get dressed in my fashionable hospital scrubs. Go play on computer (blogs, email, etc).

0840 Page from L&D, patient #1 is ready to deliver

0933 Patient #1 delivers

0950 Start making rounds on the two other laboring patients and charting on everyone

1100 Head to postpartum to see postpartum patients and chart on everyone

1145 Grab some lunch in the doctor's lounge and head over to the office

1200 Pull into parking lot of office when L&D pages, patient #3 that just came in at 8cms and feeling pushy.

1201 Bang head against steering wheel

1202 Head back to hospital with lunch in hand

1215 Arrive at patient #3's room to find her smiling and contracting every 6-7 minutes.

1216 Contemplate stepping outside of room to bang head against the wall but opt not to as I have a headache already

1216 Discuss labor support, etc with patient #3. She doesn't feel like getting out of bed at this point.

1220 Call office and tell them I will try to be there by 2pm

1240 Patient #2 is complete and starting to push, I proceed to spend most of the next hour and a half working with her, while running next door to check on patient #3, who is planning natural childbirth

1300 Call office to tell them I will try to be there by 3pm

1400 Call office to tell them I ain't coming.

1438 Patient #2 delivers.

1500 Patient #3 is hurting and just generally not having a good time. She's still the same exam

1515 I get her in the tub and I sit on the toilet. With a chux over it which turns it into a chair. I realize how bad that sounded.

1530 the tub works its magic.

1545 Patient #3 delivers

Meanwhile patient #4 is gradually getting into labor, which was the goal.

1605 Admit patient #5 for labor

1609 Sit down and try to catch up on charts, without mixing up deliveries and patients

1630 The doc wants to know if I will take over his patient as he is going off call and a doc from another practice will be covering (if the patient is ok with this). The patient (#6) has met me before and is fine with me taking over. She has also been stuck at 8cms.

1635 Bang head against the wall

1636 Utilize the magic peanut with patient #6

1645 Sit and catch up on charts

1700 Re-check patient #4 to determine the next course of action. She's definitely in labor now so onward and forward

1715 Sit down and do nothing for a few minutes.

1745 Re-check patient #6 - complete and ready to go!

1800 Call Lylaine to give report as she comes on call for the weekend

1815 Patient #6 delivers

1840 Check on patient #5, who is doing well and making progress.

1855 Leave the hospital

1900 Off call

Tiffany

I Can't Do This - birth story

S was scheduled to come in for an AROM induction (where the membranes are ruptured to hopefully bring on labor) the following day as her cervix was very ready at 4/80/-1. This would be her third baby. She had epidurals with the previous two but was really wanting to have natural childbirth this time.

S came in the day before the induction was scheduled with increasing contractions that felt stronger. Her exam was basically the same so I offered to go ahead and break her water, which she promptly agreed to :) There was clear fluid and the baby was quite the happy camper so I sent S off to walk. I wanted her to wait until the contractions were becoming more uncomfortable before using the jacuzzi tub. She walked for a bit with her boyfriend and I attended to someone else who was also laboring naturally for a bit (it was a busy 6 hours of running back and forth between the two!).

After maybe an hour, S was starting to feel more intense contractions about every 3-4 minutes, so in the tub she went. She stayed in the tub, doing squats or just lying back resting. After some time had gone by, her contractions seemed to be spacing out a bit and less intense, so I suggested walking again. I suspected that the baby may have been OP or 'sunny-side up' due to the back pain she was experiencing and the fact that labor wasn't progressing quite as fast as I thought it would (shows how much we can predict these sorts of things!).

The walking seemed to do the trick, as her labor began to pick back up again. She was also feeling a little pressure so we decided to check her cervix prior to getting her back in the tub. She was 7/90/-1 which was great progress. Things began to really pick up speed at this point. She stayed in the tub for a bit. The night shift nurse came on around this time, and happened to be a very NCB friendly nurse by the name of Kim. Fortunately Kim was able to sit tubside when I would need to leave to check on my other lady. Unfortunately, I would come back to find S getting more agitated and restless. I would then sit with her and she seemed to become a little more at ease. My other lady got an epidural around this time so was able to focus more time on S.

S started to feel more pressure so we got her out of the tub and checked her - she was now 8-9/100/0. But she was definitely hitting that transition phase. She was starting to say 'I can't do this Tiffany' over and over. She was becoming very restless. I got her back in the tub. She was asking for pain medicine but I had told her that it was too late...that she was moving along quickly now....she could do this even if it felt like she couldn't. Maybe fifteen minutes later, she started pushing in the tub. I decided to attempt to check her while in the tub as I didn't want to make her move unless it was time for the birth (unfortunately, we are not doing waterbirths...yet). She was definitely ready - 10/100/+1-2. So she got out of the tub and wanted to sit in the bed to push. She pushed for maybe 10 minutes, the entire time telling me that she couldn't do this :) She pushed out her first daughter with wonderful control over an intact perineum!

The first thing she immediately afterwards?



"I did it!"

Tiffany

ROM+2hrs=birth

I had a woman by the name of E come in for her postpartum visit recently and we were re-visiting her birth story. She graciously has allowed me to share her birth story here!

E had her first child a little premature at 36 weeks. This pregnancy was hanging on a bit more! She had been experiencing lots of bouts of contractions since about 35 weeks with some cervical change. She came into the hospital triage at 38 weeks contracting very regularly at every 2-2 and half minutes. She was 4/90/-1 (the first number is how many centimeters dilated with the ultimate goal being 10cms/the second number is effacement which is how thin the cervix is and ultimate goal being 100%/the third number is where the baby's head is in relation to certain landmarks in mom's pelvis - +3 is crowning). She walked for a bit with no change in her cervical exam...just these persistent contractions that were causing her some discomfort but not really changing anything.

I know that E was ready to be done with the pregnancy and offered her the option of AROM (artificial rupture of membranes). I explained the risks (infection, fetal distress, need for pitocin) and benefits (onset of labor!) to her as well as letting her know she had the option of therapuetic rest (little trick where morphine is given to someone in prodromal labor - will allow the woman to rest and she will either wake in full-blown labor or it will knock the prodromal stuff out) or just going home.

She and her husband discussed the choices and opted for the AROM. Her first baby had come very quickly after ROM but she was 8cms at the time. She had natural childbirth with her child and planned to do the same with this one. Once she was settled in her room, the plan was to break her water and then send her out walking, then into the tub. The ROM worked very well as E became increasingly uncomfy while walking so we moved her to the tub. She was coping very well with her contractions and working hard. She had not been in the tub long when she felt she needed to push.

She moved to the bed and I checked her cervix - she was 10/100/+1. She pushed beautifully, very well controlled and delivered her baby over an intact perineum (bottom).

I looked at the clock...total time elapsed from ROM at 4 cms to birth was 1 hour and 51 minutes. WOW!

Tiffany