Violet's birth. Part 1: Fay's negotiations.

Was it premonition, or just a standard interview, when Fay's obstetrician laid down the ground rules for laboring under her care?  Fay, Simon, and I stood in the doctor's office, surrounding the small woman with her hair in a messy pony tail, backing her against the wall.  Dr. Kim invited us there to talk about the birth plan, but instead of planning together, the interview was more of a lecture.  Point by point, she informed Fay and Simon of her procedures: what she would and would not allow.  Silently alarmed, I considered, point by point, the boundaries and tried to make sense of them.  Fay and Simon listened to Dr. Kim, nodding; I interjected clarifying questions and mentally noted the answers, knowing that a long discussion would come from this interview.  The boundaries were alarming because they would push Fay and Simon into a path of intervention after intervention, disregarding the body's natural tendencies to progress at its own rate in labor, and wholly undermining the ability of the body to give birth on its own.   Once, after I had interjected a question about her feeling about the birth party staying home after Fay's water had broken, Dr. Kim threw her arms up and exclaimed:

"If you want a midwife and a home birth, feel free to go hire one! I am a physician, and these are my rules."

I asked no more questions.

After meeting twice more with Fay and Simon before their next prenatal appointment a week later, and knowing there no time to lose, I made a list of the items Dr. Kim mentioned along with the things Fay and Simon should push for in their discussions with Dr. Kim.  Thus, negotiations began, and, armed with the marked-up list, Fay went to Dr. Kim's office the following week.


Negotiations

We had studied a list of ways to reduce the risk of having a c-section, and took some inspiration from it.  Here is the list that Fay used to discuss her birth plan with Dr. Kim, after Dr. Kim had specified her version of a birth plan.

• Bad idea: Dr. Kim would let Fay go until 41 weeks, and then induce.
  Better idea: Wait until 42 weeks to talk about induction.
  Reason: When labor starts is hard to predict.  The average gestation is 40 weeks, with anything between 38 and 42 considered normal.  The baby and the body know best.  Estimated due dates are just that: estimates!
• Bad idea: If water breaks before contractions start, labor induction with Pitocin follows after 2 to 3 hours.
  Better idea: If the fluid is clear and has no odor, wait.  Wait 24 hours.  If nothing, try natural methods.  Try natural methods while waiting.
  Reason: Contractions will usually start on their own within 24 hours.  If you are impatient, or nothing is happening, first, try to induce naturally.  Two to three hours is not long enough.
• Bad idea: Come to the hospital when contractions are 6 to 7 minutes apart.
  Better idea: Come to the hospital when contractions are 4 minutes apart, lasting about a minute, and this pattern has gone on for an hour or more.
  Reason: When contractions are 6 to 7 minutes apart, you are in early labor.  Getting to the hospital early can increase your chance of interventions leading to a c-section.  Early labor can last a long time, so it is best to be at home, where you are more comfortable and can rest and eat.
• Bad idea: Continuous monitoring with telemetry (wireless) unit upon entering the hospital.
  Better idea: If mom is laboring naturally, monitor the baby intermittently with a doppler unit.
  Reason: Continuous fetal monitoring is associated with an increase in c-section rates.  Sometimes there are things on the "strip" (monitor readout) that can be misinterpreted as fetal distress and a c-section can be called when no danger is imminent.  This is less likely to occur with intermittent monitoring.  Also, with intermittent monitoring, the nurse has to physically come in and look at you when she monitors, rather than watching your strip from the nurse's station.
• Bad idea: Progression expected is 1cm an hour; failing that, augmentation with Pitocin.
  Better idea: There is no such thing as "expected progression."  Do not put time pressures on a mom in labor.
  Reason: Would you tell people how much food they need to eat per minute?  And if they do not meet that expectation, would you threaten to force-feed them?  Every person and every labor progresses differently, and labor progress is affected by many different factors (including physical and, yes, emotional ones).  Putting a laboring mom on a time schedule only makes her nervous; it does not actually speed things up.  Things that do speed up labor include continuous support (e.g., from a doula), being allowed to move around (especially upright positions) and giving her the space and freedom to express herself.
• Bad idea: No eating upon entering the hospital.  But drinking is OK, even with an epidural.
  Better idea: Do not explicitly restrict food or fluid intake.
  Reason: Labor is hard work, and if mom is hungry, she should eat.  I have already ranted about the importance of a sip of water after every contraction, so I am glad to hear that even with an epidural, drinking is allowed.  Most moms will not be hungry past a certain point in labor because the digestion slows way down, but occasionally (especially with a long labor) mom will need some energy.
• Bad idea: Baby will be taken away after birth for cleaning unless parents expressly request to breastfeed.
  Better idea: Baby will be placed directly on mom's chest after birth, and left there for bonding for at least an hour.
  Reason: Smelling the baby.  Feeling the baby.  Wiping the baby.  Bonding.  Breastfeeding.  Oh, and the  International MotherBaby Childbirth Initiative.

It took more than one visit to clear up the questions and concerns that Fay, Simon, and I shared.  Over the next several weeks, Fay whittled down at Dr. Kim's stringent guidelines, point by point, and Dr. Kim eventually agreed to everything on Fay's list, saying sweetly that she can see what Fay wants from her birth and she will accommodate her (though not mentioning how).  

Over these weeks, outwardly, we were patient with her, and she was patient with Fay.  But secretly I had started thinking about how one transfers care after 36 weeks -- what is the process involved, and who would take on someone else's patient.  Whenever Fay or Simon asked her what Dr. Kim would do to help them labor normally, Dr. Kim would don a sweet smile, place her hands on the wall behind her, and say, "Just keep your mind open for a c-section."  I was shocked.  Fay and Simon were confused, and felt unsupported.  I began to feel that we would need to be subversive to get the kind of birth Fay wanted: "forget" to call in early labor, come in "oops-late," and refuse non-emergency procedures.  I did not like this train of thought.  It is better when the parents, doctor, and doula are all on the same page and have the same goals in mind.

In the end, the result of the series of interviews was positive, and all of our concerns were addressed with a good-natured smile: "If the mother and baby are doing well," Dr. Kim said, nodding, on all points, "that is fine."

Dr. Kim agreed to wait until 42 weeks gestation, given that she monitors the baby with ultrasound to check for fluid level and non-stress-tests (NSTs) every few days after 41 weeks; she agreed to trying all natural methods before any chemical ones; she agreed to let Fay labor at home as much as she liked, even saying she could come to the hospital for just the birth.

Due

The pregnancy progressed uneventfully.  The due date came and went.  Forty weeks.  Forty-one weeks.  Fay had passed her NSTs with flying colors, but the fluid level around the baby was shrinking.   This is normal.  It does that.  But she was late, like an overdue library book, and now it was time to start talking about induction again.

I did not attend this discussion, but I know that Fay's attitude had changed.  Going from wanting labor to start on its own and under no circumstances using Pitocin to induce or augment labor, after the visit with Dr. Kim, Fay said she wanted to induce on the first day of week 42 rather than waiting until after the weekend.  I asked why.

"I think I have lost faith in my body's ability to go into labor naturally."

After initially trying a pep talk, I sighed.  Not because of Fay's comment.  But because I sincerely felt that Dr. Kim had finally gotten to her.  Of course, it was Fay's decision, and I would be by her side no matter what.


Fay set up her induction appointment for the night before the 42nd week.  Following my advice, she again brought a list of questions with her to ask Dr. Kim.  Here is the list, along with Dr. Kim's answers.

• Can we wait a few more days?
  Reason: If the instruments Dr. Kim is using to measure the comfort of the baby (namely, the non-stress-test (NST) and the ultrasound to verify the fluid around the baby) show that the baby is doing well, can we wait?
  Answer: Though unhappy about the option, Dr. Kim said that yes, Faye and her baby can wait three more days, given a negative NST.  Then, Faye would be 42+2 (two days past 42 weeks) on the evening of the induction.
• What is the exact procedure for induction?
  Reason: Knowing is half the battle.
  Answer: Cervidil at night, then we wait 8 to 12 hours (see below).  If Fay is not in active labor at the end of 12 hours, we start Pitocin, increasing the dose every 30 minutes.  Faye expressed concern.  "In 3 out of 4 cases," Dr. Kim said, "Cervidil alone does the trick," and Pitocin is not needed.
• Can Cervidil be started in the evening before bed, with the night spent in the hospital?
  Reason: This gives the parents time to rest while letting the cervix ripen.
  Answer: Yes, it is started at night.
• How long can we wait after Cervidil for contractions to start on their own?  Can we go home to wait?
  Reason: Once the cervix is ripe and thinned out, it may be just a matter of time for contractions to start on their own, or we can use natural methods with some success.
  Answer: "No, you cannot go home after Cervidil, because we need to monitor the baby," Dr. Kim said.  "After Cervidil, we wait 8 to 12 hours for dilation to be 4cm" -- that is, 12 hours to get into active labor after administering Cervidil.
• If Pitocin is required, can we stop Pitocin after contractions have a strength and pattern that dilates the cervix (and resume trying to labor naturally)?
  Reason: Sometimes the body just needs a kick-start and can maintain a good labor pattern on its own.
  Answer: Yes.
• Once induction is started, how long do we have to deliver?
  Reason: Induction means time pressure.
  Answer: Induction in the 37th week can take a long time (i.e., when the baby and mom are not ready to deliver).  But in the 42nd week, Dr. Kim said the induction should not take long: she expects the delivery to happen within 12 to 24 hours, and said she would be willing to wait three days (the same three days to 42+2).

Everything seemed fine.  Dr. Kim agreed to let the couple come in for a NST on the morning of the start of week 42, and then induce on the evening of 42+2.


Shocker

And then, Dr. Kim added, offhand:

"And if that does not work, we can try Cytotec."  Cytotec is a pill inserted vaginally (and kept there to dissolve) in half-pill doses and it is sometimes used to ripen the cervix.

Fay and Simon rushed home to research this and were shocked -- shocked! -- that their kind (now, with some massaging) obstetrician suggested it.  Cytotec (misoprostol) has not been approved for use as a labor inducer by the FDA (though it has been used as such off-label for years), but also it is bad news: it is associated with uterine rupture (when the muscle of the uterus breaks) and fetal tachycardia (when the baby's heartbeat is too fast).

So when Fay and Simon learned about this, they felt betrayed.  They cried, "How could Dr. Kim suggest such a thing?"  Fay read more about it and was convinced that she would not let Cytotec anywhere near her cervix.  And her feelings about fighting for a natural birth were reawakened.



Continue on to Part 2 of Violet's birth, in which Fay has a baby girl.