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Here's a chronicle of life on a plot of land right smack in the suburbs in Minnesota, whose owners would much prefer to be in the middle of nowhere.

Monday, March 5, 2012

The birth of Nora: A drama in four acts

Note: This was written a few days after Nora's birth in July 2007. Since then, I've learned quite a bit, not only about how birth tends to be handled in hospitals, but about how this particular birth was handled. It was an experience that, while it ended up producing my sweet and wonderful girl, has also produced a lot of anger (at myself, my midwife, and the culture of maternity care in the U.S.). I could give you a whole list of things I would've done if I had known then what I do now, but it is what it is.

Revisions and notes are in italics; it doesn't tell the whole story to offer the sanitized version.

Cast of characters:
Me = mommy
Matthew = daddy
K = certified nurse midwife
E= student midwife
A = doula

The scene:

For the last few weeks of my pregnancy, my blood pressure was being monitored, as it was gradually creeping up. At week 38, I was put on modified bed rest, and a week later I was diagnosed with pre-eclampsia after protein was found in my urine. Sunday, July 15, K called to say that she was diagnosing me with pre-e and that she would set up a time for me to be induced the next evening, pending the results of Monday's checkup.

To add more context, my blood pressure has always been on the high side of normal (120/80); my blood pressure was creeping up from that to 140/90, which is the threshold at which providers want to make a diagnosis of pre-eclampsia. I have also since learned that it's very normal for women to have at least some protein in their urine toward the end of pregnancy. Aside from swelling, which would be better attributed to being pregnant during July and living in a house with inadequate air conditioning, I had no other symptoms of pre-eclampsia. During the time period leading up to being induced, my midwife also told me I should stop consuming sugar (though I passed the gestational diabetes test with flying colors) because my A1C level was at the high side of normal. She also requested that, for reasons she didn't explain, I get a biophysical profile. I initially consented, but after sobbing in the car for awhile, went back in to tell her I wasn't going to do it, because I didn't feel it was warranted. In retrospect, it seems clear that she had lost trust in my ability to be pregnant and give birth, even if I hadn't, and was eager to set the scene for induction for a "big baby" or pre-eclampsia or... anything.

On Monday morning we went to K's office expecting to take her advice to induce that evening, but the plans changed after the appointment; K wanted us to go to the hospital right then, after stopping home to get our bags and tie up loose ends. Since an exam showed that I was 2 cm dilated and 75% effaced, we could skip a cervical ripening agent and start Pitocin immediately; we'd hopefully have a baby soon after. Somewhat reluctantly (given how gung ho I am about natural childbirth), I agreed. K stripped my membranes while I was there, so I had some delightful cramping after that appointment.

After we got our things taken care of, A met us at our house, and we began the two-block trek to the hospital. We got to labor and delivery around 1 p.m. and were told we'd need to wait; there were no rooms available. We joined another woman and her family (they'd already been waiting an hour) in the rather uncomfortable waiting room, and finally got into triage at about 1:30. The fetal monitor was strapped onto me and I was instructed to lie on my side (something I was all too accustomed to, having been on bed rest doing the same thing for almost two weeks). They fed me, some time passed, and we got the go-ahead from K to start my IV of Pitocin.

This was induction attempt #1. Hours later, I was having regular contractions but not feeling them, and another exam showed no progress from earlier in the day. K and E came to discuss my options, and they strongly favored admitting me and trying a cervical ripening agent overnight. Again, I agreed somewhat reluctantly; I felt a little bit betrayed at this point, since K had seemed so confident that it would work the first time, and I felt strongly, as well, that my body wasn't going to produce a baby unless it was ready to do so.

We were transferred to a much, much nicer room with a somewhat more comfortable (though that's not saying much) bed. After I was allowed a shower, on came the fetal monitor once more. Around 9 p.m., K and E placed Cervidil on my cervix and told me that I'd need to stay on one side for two hours and recommended that I take something to help me sleep. I attempted to bypass that, but the pain in my hips was so distracting that I ended up taking four of something-or-other. It didn't knock me out like the morphine they wanted me to take, but I did get some sleep. Since the fetal monitor had to be readjusted every time I switched sides, my hips were still not happy in the morning.

Induction attempt # 2 yielded the same result as #1 - nada. My cervix didn't change at all, so K suggested pressing on, this time using Cytotec. This should pack a wallop, she said; the wallop for me ended up being "maybe 3 cm." As in, I was now maybe 3 cm dilated. Induction attempt #3: FAIL.

This, by the way, was after she asserted that babies who are induced because of pre-eclampsia end up coming out FAST, like they know something is wrong. This is a statement I've heard echoed by other people whose philosophies fall all over the spectrum of maternity care, so I can believe it. But it also leads me to believe that neither me or my baby were in any danger whatsoever. Even if we were, since I was so close to my due date (two days before, precisely) and showing no severe symptoms, my midwife could have taken a wait-and-see approach. Pre-eclampsia, while it is certainly to be taken seriously, is generally less of an emergency when it occurs later in pregnancy.

During this time, I was pretty darn uncomfortable and unhappy. I was confined to bed, both due to my high blood pressure I really should call it "high blood pressure," including quotes, while relaying the story, since my blood pressure was, and always had been, under 120/80 while I was lying on my side during this fiasco and the weeks prior. I asked my midwife the question, "If I really had high blood pressure, wouldn't it be high regardless of my position?" and she ignored me every single time I asked. and the constant fetal monitoring, except for brief stints to the bathroom, and stuck on either my right or left side. We did figure out that placing pillows under and around me helped increase my comfort level somewhat. I was adamant that if I were allowed to get out of bed on occasion - not to walk around, just to stand up - that this would start chugging along. Unfortunately, each request was shot down. Of course, I was told I could do whatever I wished, but it was strongly recommended that I stay on my side. More accurately, I was told I was at a high risk for having a seizure and my midwife didn't want to have to put me on magnesium sulfate. My response was, "I'm in a hospital. Isn't that the BEST place for me to have a seizure if I'm going to have one?" No response to that, of course, just repeating that I should stay in bed. But it was about to get unhappier!

K and E came to me around 3 p.m. with their last-ditch effort: We'd restart the IV Pitocin and break my bag of water if the contractions weren't enough to change my cervix on their own. I really, really did not want my water broken at any point, largely because I tested positive for Group B strep and didn't want the baby exposed to that any longer than she needed to be. Once those waters break, you're on a timeline, and I also have heard that Pitocin-induced contractions are pure hell after your water breaks. The alternative? I could go home and we could try again in a day or two, but that brought with it additional dilemmas: What if I got sicker? What if the baby was put in danger? K refused to go ahead with the plan if my answer remained at "It pains me to say it, but yes," so I had to work it up inside me to fully commit to the plan. I got as far as, "I guess," but, for me, that's commitment.

The Pitocin was restarted shortly after 4 p.m. This time I was feeling contractions more frequently, and feeling those more strongly, but it wasn't enough on its own. K's backup OB was called in to help break my water, as the baby's head wasn't quite in the correct position. (A was impressed with the consideration shown to this, as she hadn't heard it before.) At around 5:30 p.m., my water gushed its way all over the darn place; that was a pretty awesome sensation. To complicate matters for yours truly, they placed an internal monitor in to measure my contractions and also one on the baby's scalp.

Did anyone ask before placing either internal monitor, or even give a heads-up that it would happen? Nope. It was announced that it was done after it had been done. Again, this was something I was very concerned about because of the Group B strep issue, but apparently I was the only one who thought about that. To add insult to injury, I really, really, really had to pee at that time, and if I had known anyone would be shoving wires into my uterus and baby, I would've used the bathroom first. Instead, I had to squat onto a bedpan in front of everyone. The internal monitors were just one part of my birth plan that was ignored; in fact, the whole thing was ignored the moment I consented to induction.

Every contraction I felt until this happened and been bearable - pleasant, even. Once the baby's head hit my cervix - whoa, mama. They came hard, and they came fast. I was told that I was having a contraction every two minutes, but those were the fastest two minutes of my life. A helped me breathe through each one (sending the breath down through my cervix and envisioning it opening), though I realized it would be more helpful to go through each one by myself, when I could. Matthew stayed off to the side, which I appreciated. There were so many people going in and out and touching me and there was so much noise... It was tremendously overwhelming, and if I had time between contractions to catch my breath, I would've lashed out very, very strongly.

At some point, K came to tell me that my liver enzymes were elevated. That is, I was getting sicker. Just another thing to add to the list of things to freak out about.

I had the pleasure of reading through all of my records when I got a copy to give to my new/current midwife. All my labs were fine the whole time.

I was so, so mad that I couldn't move anywhere, because it HURT. The problem was that the baby was coming down very quickly, so between each contraction I felt very intense pressure in my lower pelvis. I didn't have time to compose myself between contractions. There was begging (from me) for drugs. There was the typical "Let's just wait until this contraction is over" response. (I wanted to yell, "BULLSHIT, I KNOW WHAT YOU'RE TRYING TO DO.") While I was able to get through most of the contractions fairly well, there were plenty of panicky ones in there.

K came to check on me and reiterated what she said earlier about my liver enzymes being elevated, as I really, really wanted to get out of bed. Then she said, "We're going to repeat the bloodwork at 9:30," and I think that - along with the acceptance that the contractions were going to hurt so I might as well suck it up - was the turning point for me. It also might've helped that E went home just prior to that, with the intention of returning. For some reason, I didn't want her around when I gave birth.

I had this very strange contraction that felt like my uterus was having its very own earthquake. I told K, "This feels very different." She said, "Different how? Pain or pressure?" and went for her gloves as I said, "I don't know - both?" She checked me and I was at 7 cm. Commence frantic scrambling on her part. She explained that she was getting a bunch of people together to help with the baby. I think I cut her off midstream with my sudden urge to push. I keep remembering the tone of her voice, because it struck me as funny and so matter-of-fact, when she said, "You're pushing, aren't you." She checked me and I was already at almost 10 cm, and this time things got REALLY frantic. She was concerned about shoulder distocia, so they wanted to tilt the bed up and get me near-vertical. She let me push as I wanted, though, all but the first couple of times.

And, oh, pushing felt good after that. It was a very odd sensation that I didn't have much control over at all; I couldn't imagine having someone attempt to control whether or not I pushed. Between contractions, I had a blissful period of rest. The pushing wasn't too bad, although I did scream once, attempting to keep my voice down and low (unlike the lady in the next room, who screamed bloody murder for a good hour; I'm so glad I couldn't hear that).

I was almost vertical, my feet in stirrups, and was instructed to grab onto the backs of my legs; a couple of people helped to hold my legs back. K was literally counting down as the baby came out, and I had about ten people around me yelling for me to HOLD MY BREATH instead of blowing it out. I was a little too focused to care what the hell they were yelling at me. The nurse I really disliked was the only person I remember being yelled at by, and she kept yelling even as I got the baby out. Take that, you annoying nurse!

What I remember most about pushing, now, was that I had about a dozen people around the bed, and the nurse who was by my head stuck her face directly in mine and SCREAMED at me not to scream during contractions. You can imagine that I felt very supported...

Oh, and all this talk about shoulder dystocia? The baby practically flew out of me, without assistance.

I didn't enjoy the next part so much. They took the baby to the corner of the room and did whatever they usually do to babies. Matthew sort of ran around being happy and snapping pictures like a Japanese tourist (that part was cute, not bad). I sat around with my blood pressure getting automatically monitored while I was attempting to see my baby and getting stitched up (two minor tears - four stitches - and a couple of skid marks) and having blood drawn and having my uterus massaged and clots pulled out. I very much wanted my baby, but I didn't get to hold her for almost a half hour. Grr.

This was despite asking - and begging - "please let me hold my baby." At several points, she was in a small plastic bassinet across the room without anyone around her whatsoever, screaming the whole time.

Eventually, I got to hold her, and she was perfect. And then we got a recovery room and spent the next couple of days having everyone and their neighbor popping in at almost all hours and me being entirely unashamed if they happened to catch me with my boob out. Serves you right!

Nora had quite a few visitors. We ran into her aunties Annie and Amanda on the way to our recovery room. Grammalinda stopped by sometime the next day (we both slept through that visit!). Smae and Al and Grandpa Frank came by later that day, too, and our neighbor Susan, who works in the hospital, visited right before we came home.

Things are going okay. Matthew and I are a little in shock that we're actually parents, but we agree that we're doing pretty well. Matthew's such a proud daddy and has already showed her off to the neighbors and enjoys dressing her up. Nora is a very heavy sleeper; that's both a good and bad thing. We're all well-rested at the moment, but it makes it very difficult to wake her up to nurse regularly.

Breastfeeding is a hell of a lot more difficult than I anticipated. My 42DDs are only getting bigger, but my small nipples aren't growing much. It's difficult for Nora to latch well, particularly on my right side. I'm going to haul out the breast pump to make sure that one's getting the stimulation it needs (though whaddya know, she just nursed for a good 20 minutes on that side). I haven't seen any direct evidence that my boobs are producing anything, but we've had lots of wet diapers. There were lots of poopy diapers while we were in the hospital, but I don't think we've seen one since we've been home. We've been using cloth diapers in order to tempt fate and to get rid of the poor little irritated bottom she has thanks to all the disposables.

Breastfeeding wasn't helped by the hospital staff, certainly. I saw a lactation consultant twice for about five minutes each time. The first, she breezed into the room, introduced herself, grabbed my breast and squeezed a nipple to show me that I had colostrum, and helped me shove the baby on the breast. If Matthew hadn't been paying attention, I would've had no clue what I was doing. As it was, I didn't have a clue anyway, and none of the various nurses we had were helpful. At least no one suggested giving a bottle, though one nurse did suggest putting formula on a nipple to convince Nora to try to suckle. The lactation consultant came by the next day and was cheery and encouraging but not helpful. We finally had a decent, supportive nurse right as we were being discharged (which took forever, and we sat around for hours before getting the all-clear), though her idea of support was to make sure I got the "breastfeeding support kit" that had more cool stuff than formula; there was just one can instead of several. It is through the miracle of the internet (that is, Kellymom), a whole lot of hardheadedness, and my husband's support that we managed to make breastfeeding work.

I do think we're well on the road to getting to know each other, though, and it's pretty darn awesome.

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