A very short birth: Emergency Caesarean and doula support

What follows is my account of an emergency C-section birth, from the perspective of a support person.  This birth changed my perspective as a doula.

Clay and Erin are the perfect young couple.  At our first meeting, they hugged and touched and giggled, rubbing Erin's round belly and kissing each other sweetly.  He was a military man with a hint of a southern drawl; she was a fair-skinned, red-haired maiden glowing in her pregnancy and reminding me of Loreena McKennit earth-mother songs.  In her belly incubated baby Amber, soft and warm, caressed from all sides by her mother's lovely warmth.

The morning of baby Amber's birth, Erin went to her scheduled prenatal appointment and was delightfully surprised (yet slightly apprehensive) to find that she was 3cm dilated.  "Today or tomorrow," Dr. Draper said, smoothing his grey moustache.

At 5 that evening, Erin called and told me of her first contractions.  "They feel different," she said, comparing them to Braxton-Hicks contractions in her excited, fluttery voice.  We checked in again at 7, when the contractions had suddenly intensified.  I suggested keeping hydrated, taking a shower, or taking a walk.  I remembered back to another recent birth in which the early labor contractions suddenly got intense, and how terrified I was that I was missing active labor.  But when we arrived at the hospital, we were just at 3cm.  I know that every mother is different, and every birth is different

At 8pm Clay called.

"We are thinking of going to the hospital," he said, and confessed that Erin was vomiting profusely with and through every contraction.  They were having a hard time keeping on top of them.

"Can you wait for me to come?" I asked.  "Help Erin take a shower or a bath.  I will be at your house in an hour."

"I don't know," he said.  "I'll call you back."

I packed my bags.  Five minutes, ten, fifteen went by as I sat by the door with my bags.  Suddenly, I knew that they had gone to the hospital.  I left.  Fifteen minutes on the road before I got a text message from Clay: "Come."  They were at the hospital.

Terb-ulent contractions

I arrived at 9:20 to find Erin in a gown in the bed, monitored.  Contractions were light and infrequent. I talked with Clay and Erin until the nurse came.  She said Erin was between 3 and 4cm dilated, 90% effaced, at +1 station, with no change from admittance an hour prior.  She was administered terbutaline, an injection just under the skin (usually in the arm), to stop labor.

Of course, as soon as I got home, I looked this up.  Terbutaline, or terb, for short, is frequently used to stop preterm labor, but its use here, as a labor inhibitor, is controversial because controlled studies are lacking.  In 1997, the Food and Drug Administration (FDA) wrote:

In the absence of data establishing the effectiveness and safety of the drug/device, FDA is alerting practitioners, home health care agencies, insurance carriers and others that continuous subcutaneous administration of terbutaline sulfate has not been demonstrated to be effective and is potentially dangerous.

In this case, it was not a continuous dose but an intermittent one, and it was not for preterm labor but for a full-term baby.

I did not fully understand the reason for administering terb until I had a chance to glance over the charts that the nurse collected from the contractions and baby's heart beat.  With and after every contraction, the baby's heart rate plummeted.  Not just a little.  A lot.  I did not know this until much, much later.

By 10:15pm, contractions had picked back up with terbutaline wearing off.  And, as before, Erin vomited violently through every contraction.  Clay held a bucket by the bed; the nurse and I took turns emptying it in the sink.  There was exactly enough time to clean the bucket and get it back to the bed before another contraction required its assistance.

But the baby's heart rate was again decelerating with each contraction.  The nurse started the oxygen mask flowing and called the doctor.

I suggested some position changes.  We tried the hands and knees position on the bed.  Erin hated it... but over the next two contractions, the heart rate deceleration showed a marked improvement.

Fluid around the cord

At 10:30, just fifteen minutes after our position changes and oxygen mask, Dr. Draper arrived in a shirt and tie under a white gown.  Barely greeting the couple and not glancing at me, he looked at the charts as the nurse caught him up.

"Yes, I see that," he murmured to the paper trail of contraction bumps and baby dips.  He turned to the nurse.  "Who is the anaesthesiologist on call?" he asked as my heart sank.  My heart sank and my blood pressure rose and my face burned.

I glared at Dr. Draper with all my might.  I glared at him as strongly as one woman could glare at a man.  I glared at him and shot little lightning bolts from my eyes as I sat nearby Erin's bed, and as I watched her glance sweetly, sadly, timidly, frightenedly at Clay.  I glared because I knew that with just a few more minutes, with just a few more position changes, with just a few more attempts we could fix this thing.  We could have our birth.

Dr. Draper turned to Erin and Clay and pushed his glasses up on his nose.

"Fetal intolerance to labor," he said.  "I can prove it to you," he added as he asked for a portable ultrasound machine.  He called up on the black and white display a blurry image of some moving black and white bits.  Erin had a contraction and started puking.  Clay looked at her face and at the bucket and at the monitor and at her face.

"You see that there?" Dr. Draper said to us.  "See, that's the umbilical cord.  That's the contraction, and here it's being compressed. There is no fluid around the cord."  As the contraction ended, he pushed aside the machine and waited to have Erin's undivided attention.

"We need to get the baby out now. You know how I know? Because I've seen it before.  I have seen this a hundred times before. I have made this mistake before.  If we wait, the baby will not do well.  We are so early in labor, and already the baby is not handling it well.  We cannot wait.  I have seen this before."  Erin nodded throughout and agreed that whatever is safer for her baby she is willing to do.

With my hands folded and my voice calm, I turned to Erin and Clay and asked, quietly: "Do you have any questions?"  Erin and Clay shook their heads.

"May I be in the OR with them?" I asked, ready for a fight.

"Yes," said Dr. Draper and walked out of the room with some mumbled instructions to the nurses.  He called the c-section at 10:40pm.

The room started bustling.  One nurse gave Erin another shot of terb just as a contraction was starting. Clay readied the bucket.  Another nurse brought an OR kit -- hair net, gown, and mask -- and placed it on the bed for Clay.  "One more, please," I said; the nurse nodded and left, reappearing with another set.  Erin and Clay both received arm bands and a tiny one was prepared for the infant.  Other infant items materialized: a baby warmer, a bassinet.  As this was happening, I went to the nurse and asked:

"What is Dr. Draper's c-section rate?"

"Oh, I don't know," she said.  "Probably like the rest of the hospital.  Thirty-three percent."  I was interested to know this because this particular hospital is privately-owned and does not publish its birth statistics.  The c-section rate was at the US average.  Knowing this added fuel to my already-burning fire and I seethed, confident in my opinion that the doctor had made a hasty call.

"Do you guys do VBAC?" I asked, meaning vaginal birth after c-section, an option for many women.  I kept thinking about Erin's beautiful round belly.

"No, we can't do VBAC here," she replied sadly.

Erin was wheeled to the preparation room; Clay and I were escorted to the recovery room to wait. This empty, lifeless room had two hospital beds, sterile floors, and a chilly atmosphere.  We dressed in our yellow hospital gowns.

"I guess it's time to tell the folks," Clay said after several minutes of silence, and began sending text messages on his phone.

We tried to play guess-the-time-of-birth, but the mood was somber.

Birth

Finally, the nurse called us in to the operating room.  Erin was on the table with bright lights beaming down on her tired, worried face.  Clay's touch was clearly soothing, comforting.  I stood nearby with the camera and took pictures, explaining what I saw.  I was careful not to take any photos of the incision, as the doctor requested.

"Now he is cutting the fat layer," I said.

The nurse exclaimed: "Not that you have hardly any fat layer at all!"

"Now he is opening the uterus.  Now he is breaking the bag of waters."  The suction device picked up dark, chunky fluid, stained with meconium, and transported it through a clear plastic tube to a receptacle.  "Breathe through this part," I suggested, remembering the previous c-section that I attended, in which the doctor wrestled the baby out over the course of what seemed like an hour.  "You'll feel some tugging. Now he is lifting the baby's head.  The head is born.  Now the rest of the body."  There was not as much tugging as I anticipated as the baby entered the world, a dozen hands holding her up.

Dr. Draper delivers baby Amber as nurses stand by.
Photo by PhDoula.

Time of birth: 11:26pm.  The nurses took the baby to a warming station and vigorous rubbing began.  Unlike the previous c-section that I had seen, Clay was not allowed to go to the baby.  Clay and I watched both Erin and Amber.  Every few minutes, I would ask: "Can Clay go to the baby now?" but the answer was always no.

Dr. Draper talked as he operated. "Yes.  I have seen this before.  The cord was around the baby's head, and it was being compressed between the head and the uterus. It's called a nuchal cord."

After cleaning the area thoroughly, Dr. Draper continued: "It used to be cool to have 10, 15 years of experience.  But I have been doing this for 25 years, and it makes me sound old."

I asked: "How many babies have you delivered?"

Dr. Draper said, "Thousands."

Choosing his scythe-shaped needle and clear thread, which reminded me of liquid cat whiskers, Dr. Draper began sewing.  "Hmm, yes, I think I can sew this together in just one layer.  Look at that.  It just lines up together perfectly."

Shocked, I asked: "One layer? Is that safe?"

He replied in the same pensive tone: "Yes, in this case it is."

I paused.  "Can Erin have a VBAC after this kind of stitching?"

"Yes, I don't see why not."

"But you don't do VBAC."

"No, we can't do VBAC here at this hospital.  But I can give a referral to someone who does."

Afterwards, I learned that the two- versus one-layer stitching debate was a sore spot for many women.  The debate goes as follows.  One study (Bujold) found that single-layer stitching (discussion, editorial [PDF]) showed an increase in cases of uterine rupture in VBAC patients over two-layer stitching.  However, the study had two serious flaws.  First, the hospital staff was not as familiar with doing the two-layer stitching as single-layer stitching (so expertise was an issue).  Second, the materials used to do the closure were not as strong as we have today (so equipment was an issue).  Furthermore, there is good evidence that, when the fibers of the uterus line up well (as was the case here), single-layer stitching is just as good as two-layer stitching, in that it is strong, it has good structural integrity, and it is unwilling to be compromised under stress (e.g., through a subsequent trial of labor).  Although some doctors simply will not even attempt VBAC with single-layer stitching, others will.  Unfortunately, much of it depends on the doctor and on his or her insurance carrier.

The nurses brought a loosely-swaddled bundle to Clay.  "Congratulations," they whispered, as they handed baby Amber to him.  Clay held her like a freshly-baked loaf of bread, typical of the new father, and stooped low so that Erin could also see her sweet newborn face.   They gazed together into her sleepy face with misty eyes, huge smiles, and little kisses.

After the stitching was over, Erin was bumped from the OR bed to the regular bed, and was wheeled to the recovery room where Clay and I had paced the confines of this sterile enclosure just an hour earlier.  The nurses took baby Amber from Clay's hesitant arms to the nursery.

After a few minutes in the recovery room: "Does the baby have a name?" the nursery nurse, in charge of the infants, asked as she entered the room.

"Yes -- Amber," Erin replied.

"We need to keep Amber for a few minutes in the baby warmer.  She is cold."

While we waited, we talked about the baby and how strange it was not to be pregnant anymore.  Erin and Clay talked about which family to tell, whom to call.  We examined in great detail every single dial and switch on the walls.

Every time the nurse came in, I asked: "Can Clay go to the baby?" or "Can Erin have the baby now?" or "Is the baby coming soon?"  Twice, I sent Clay to go find the nursery and look at the baby through the window.  Both times, he reported back that the baby looked fine.

It was clear that my job had become the nagger.  I nagged during the surgery, and I was nagging now.

Finally they brought the baby.

Breastfeeding

As baby Amber was wheeled into the room, I had the impression I was watching a wedding.  Erin and Clay looked at the baby, and I looked at the parents looking at the baby.  Their faces expressed unbounded love and devotion, the kind of eternity people everywhere seek but do not know where to find.  Their arms reached out to this new life.

 He handed her to Erin.

"Oh, my little bird," Erin cooed, her eyes filling with tears.

I sat off to the side and snapped photos of the new family.  In a while, Amber began to open her mouth wide and lick Erin's shirt: clear signs of interest in nursing.  Swooning, I took more photos.

"Yo, doula," Clay said, "get over here."  We laughed as I helped position Amber on Erin's chest.  This was not an easy task given that Erin was completely numb below the ribs.

In the wee hours of the morning, Erin, Clay, and Amber were sleepily settled in their room, and I left.


Conclusion

We all go into births with some prejudices, whether or not we know about them.  For some doulas, it is the idea that the epidural is the root of all evil; some doulas see birth as a magical gathering of rainbows and unicorns as a baby emerges perfectly into the world.  Students of  Ina May describe contractions as "rushes" so that the mother imagines them as energy rather than pain.  For me, it was a distrust of medical doctors and especially their reasons for conducting c-sections.

At every step of the way, mentally, I challenged Dr. Draper, distrusting his reasoning and his methods, because doctors are prone to disregard the mother and treat only the condition.  Because doctors hate to wait for a birth to come around on its own.  Because vaginal birth is inconvenient and c-sections are faster.  I challenged him when he made the call for a c-section; I distrusted the size of his incision; I questioned his choice of suturing method (and what an expert I am, right?); I frowned at the separation time between mother and baby.

When I went home after Amber's birth, I researched all of the things Dr. Draper said, and read a great deal.  I worried about Erin and Clay: were they upset over this turn of events?  Were they unhappy with their c-section?  I had no idea, but other reading I had done (e.g., Pushed, Woman in the Body) suggested that women frequently have negative affect after an unscheduled c-section.  In my research I was both convinced in the doctor's expertise and embarrassed at my emotional reaction to the events of the birth.  So then in a sort of apology, I sent Erin and Clay this e-mail:

Congratulations on your baby girl!!!!  Amber is so small and sweet.  :-) 

I just want to follow up with you and make sure you know that you and Clay totally made the right call.  In fact, it wasn't your decision to make at all: Late deceleration is a definite cause for alarm, and persistent late deceleration at 3-4cm is a very good reason for a C-section birth.  Amber wasn't doing well with labor, and didn't have enough oxygen in reserve to make it through the contraction.  During a contraction, there was a normal decrease in the amount of oxygen exchanged between you and Amber, but she didn't have enough oxygen stored up to make it through each contraction. 

Please don't feel sad; you did the right thing, and you had the right birth. 

You and Clay were rockstars during the labor and during Amber's birth; you were both doing so well!  You are an amazing and powerful birth-woman.

When we met for a postpartum meeting, Erin and Clay confided that they know they did the right thing, and there was no doubt in their minds. There were no hard feelings between them and their birth.

I was relieved.

This birth changed me as a doula.  I became a better listener, and a better question-asker.  I became more patient and more humble.

Should we go into interventions blindly?  No.  But we should be prepared for everything... and we should ask questions until we are satisfied with the answer; until we know, without a doubt, that we are doing the right thing.