One woman's path through doula training, childrearing, and a computer science Ph. D. program

Friday, September 9, 2011

Violet's birth. Part 2: Fay gives birth.

Read Part 1 of Violet's birth, in which Fay negotiates with Dr. Kim in the weeks before her due date.

That night, the day of the NST and start of the 42nd week, Fay's belief in her body was reinstated as she lost her mucus plug and had some mild contractions for about an hour, but then they stopped.  I did a little dance of joy on her behalf, because I knew that her body was getting ready for it.

And that night, Fay and Simon went in to the hospital to have their NST.  With the nurse's help, Fay climbed up on the hospital bed, turned on her back, and --


"Did I pee?"  She wondered.  "Is it blood?"

She looked down.

Nope, not blood.  It was clear and odorless.  The nurse turned to her and smiled.  Fay's water had broken.  Simon looked on.

"I guess you're staying now," the nurse said.  "I'd better admit you."

Non-stress test (NST)
"Deliver, not rest."

Admitted to the hospital, Fay lay on the hospital bed and looked at Simon.  "This is it!" she thought.  The non-stress-test (NST) was beeping merrily on the cart beside her.  The nurse entered, and Fay said:

"I think I'm having a contraction. I can feel it in my back and my belly."

The nurse looked at the monitor.

"Doesn't look like it," she said.  "But we'll have to get them started four hours from now.  I'll bring the Pitocin."

Fay and Simon looked at the clock on the wall.  It was 11pm and they were exhausted.  Fay remembered my advice to her: sleep when you can in early labor.

"Can we wait?" asked Fay.  "Until morning.  So we can sleep and be well-rested for the Pitocin in the morning."

The nurse rolled her eyes.  "You came here to deliver, not to rest."

Simon spoke next.  "No, actually." He cleared his throat.  "We came here for a non-stress test.  We did not come to deliver."

Fay asked, "Can we go home?"

"No," replied the nurse, her voice raising in annoyance.  Collecting herself, she added:  "Well, yes, but you would have to sign this form in which it says you are leaving against doctor's orders.  What happens to you outside this hospital," she closed her eyes and spread her hands, palms up, for dramatic effect, "is out of my hands."

Fay and Simon looked at each other.

"We'd like to wait eight hours before Pitocin."

"What difference does it make?" huffed the nurse.  "If labor doesn't start in four hours, what makes you think it will start in eight?"

Fay and Simon blinked at her.

"Fine.  Fine!" she scolded.  "You can have six hours.  I will be back to check you in four hours, at 4am.  Then at 6am I will start Pitocin."

"Deal," Fay and Simon said, and breathed a sigh of relief as she waddled from the room.

Sleeping labor, and active labor

Simon slept on the roll-out partner bed.  And in her sleep, Fay had contractions.  She woke up for each and every one of them.  The pain radiated from her back, and with each contraction she would wake up and press her back into the bed with all her might.  The counter-pressure was a relief but the pain was exhausting and all-consuming.

At 4am, the nurse returned and checked Fay's cervix.  It was 4cm dilated.  The nurse was defeated.  Packing up her Pitocin bags, she left the room and left Fay to labor, quietly, on her own.

At 6am, Fay called me, her doula, to come.  In the meantime, I told her, get on all fours and have Simon squat over you, putting pressure on your back with his hands.  On your back in bed is the worst place to be.  And drink some water.  And try the shower.  Water on the back may feel nice.

The doula comes

When I arrived, Fay and Simon were in the bathroom, with Fay in the shower.  The room was hot.  I knocked and pushed open the bathroom door as steam poured out.  I closed the door behind me.  There was a floral scent of shampoo, and with each contraction, Simon would lean into the shower and press on Fay's lower back.

"The pain was easily ten times worse in the bed," said Fay.  "It was unbearable.  It is so much better here in the shower, but my back still hurts during contractions."

"Sometimes back labor is caused by the baby presenting in an odd way," I said.  "She's probably pressing with her head on your spine.  Being upright and leaning forward like you're doing will help the baby turn a bit."  When we get out, I thought, we will try hands and knees, kneeling, and lunging.

"Ohhhh," said Fay as a contraction hit, turning her back toward the hot stream.

"The bonus is that in this shower, you won't run out of hot water."  I smiled and Fay copied my smile.

I heard some noise outside the bathroom door.  "I'll be right back," I said and excused myself.

Pain scale. I just want to punch someone when I see one of these in labor.
How much does it hurt?

In the room, a nurse, Katie, was standing with another woman whom she introduced as one of the nursing teachers.  I told Katie I am Fay and Simon's doula, and Katie exclaimed that she was so cool with doulas, unlike some other nurses, and that we would work well together.  The shower turned off, and in a few minutes, Simon and Fay emerged.

Katie did her work, taking blood pressure and temperature readings and setting up the monitors to listen to the baby.

"I don't usually ask this," she said, blowing her bangs out of her eyes, "but, on a scale of one to 10, ten being the worst you could possibly imagine, how would you describe your pain right now?"

I rolled my eyes.  Here we are, Simon, Fay, and I, trying to keep Fay from seriously thinking about her pain, trying to keep her distracted and taking things one at a time, and now she is expected to put a number on her sensation.

"In the bed," answered Fay, "it was bad.  Like nine.  I can't imagine it being worse.  But in the shower the pain decreased tenfold; probably a four."

I stammered: "Can we, uh, not do that again?"

"Yeah, sure, it's just one of the vital signs," explained the nurse, who probably saw me rolling my eyes anyway.  "Temperature, blood pressure, pain level.  We have to take it every hour.  If you want, I can just fill in numbers from now on.  Six, seven, six, seven."

Simon and Fay nodded, watching me.  I nodded vigorously.

Katie pulled on a sterile glove and checked Fay's cervix.  Fay held Simon's and my hands.

"Five centimeters," Katie announced.  "I think it is great you are laboring normally," she said, not looking at anyone in particular, and added that natural labors usually are assigned to her because she is so awesome at "dealing" with them.  Then she started talking about what a "good" labor pattern looks like and how we can tell that we are "progressing well."  She pulled up a chart showing 1cm per hour dilation.  Simon looked on, and I, knowing that talking about expected progress is not encouraging, sat by Fay's head and talked to her about her night in the hospital.

"I'll be back in about an hour to take your vitals again," Katie said.  We thanked her as she left.

Counterpressure to lower back
Fired from birth support

We labored normally for several hours, changing positions frequently.  We tried every position that I could think of to try to alleviate back labor.  I coached Simon how to spread his legs, lock his elbows, and use his back to push on Fay's lower back during contractions as Fay leaned forward on a stack of pillows on the raised bed.  If his hands slipped, or he changed his grip, or he got the wrong spot, Fay would scold him for a good half of each contraction -- and then we would all laugh as the contraction eased.  Laughter brought on contractions.  Walking brought on contractions.  Touching Fay brought on contractions.  We joked that we could not do any of these things, and if we did, Simon would be fired.

Simon was fired from labor support eleven times.

At 10:30, just two hours after the previous cervical check, we had progressed to a heartening "6cm, almost 7."  Things were great.

But at noon, something happened.


We were sitting in the middle of the room, with Fay on the birth ball between contractions, Simon in the glider, and me squatting at Fay's knee.  We heard a noise next door.  It was a woman.  And she was screaming.  She screamed for what felt like an hour, though it must have been just a minute.  She would stop screaming only to take a sharp breath and then the blood-curdling scream would come again.  Under the woman, we could hear other people's loud, mumbled voices.

Fay looked at me.

"She is not doing as well as you are," I said, smiling.  "Those are bad noises to make.  You are making good noises."

The screaming continued.  Fay stared at me.

"She is probably delivering," offered Simon.

The screaming continued.

"Oh my God," said Fay, the color draining from her face.

"It isn't necessarily pain," I said.  "The sensation is overwhelming.  This is why she is screaming."  We all looked at the floor, waiting for it to stop.

The screaming increased in pitch for a split second.  We held our breath.  Then, the screaming stopped, and was replaced by tearful shouts: "Oh, my baby, my baby!"

I looked at Fay and smiled.  She was crying.  Tears were rolling down her face.  I looked at Simon.  He was pale.

We talked about it.  We talked about fear, and how we need to get past it.  About how the baby is coming today, and we are helping her come.  About how most women do not sound like that.  Fay did not talk about delivery.  She was trying not to think about delivering the baby, about pushing the baby out, about the woman screaming next door.

Fay was exhausted.  Climbing into the bed and rolling onto her side, she fell asleep in no time. Though I tried to convince Simon to sleep, he and I sat near each other and talked.  We would chat, and then Fay would wake up with a contraction.  We would rush to her: Simon to her back, me to hold her hand.  Then it would ease and she would drift off.  This happened infrequently: contractions slowed to a crawl.  Every seven minutes.  Every ten minutes.

The drill sergeant

At 1pm, I went to fetch the nurse.  Because contractions seemed stronger, though infrequent, and there was that electric feeling in the air, that particular odor that I have come to associate with transition.  Katie came back in and, checking, we were pleased to hear we were 7-8cm.  Which is almost transition.  It is close.

"I've had some women complete on the toilet," Katie suggested, meaning that women dilate the rest of the way, to 10cm, or "complete" the dilation.

"Try the toilet," Katie continued.  "Try the shower.  Try nipple stim.  We gotta get things moving."

Determined to do everything I can that we should get through this part, that is, transition, quickly, I got Fay out of bed (bribing her with getting back in it later) and we went to the toilet.  Then the shower.  Then the birth ball, with her legs spread wide.  I kept waiting for that contraction with the pressure on top which indicates real transition, but I did not hear it.  It did not come.

Acting as a drill sergeant, I sent Fay back and forth from the door to the baby warmer.  She did laps around the room, and I suggested she try some nipple stimulation.  She ate a little bit.  She drank water.  We tried effleurage, in which Simon gently rubbed Fay's belly to bring on contractions.  But contractions were still slow, and there was still no pressure at the top.
How to do effleurage in labor

An hour later, at 2:30pm, we learned that we had made no progress.

At 4, Katie returned with a vengeance.  She showed us the graphs again (and again, I distracted Fay from seeing them).  She talked about progress and how we were not making any.  And she gave Fay two options: an epidural, which would help her relax, and the relaxation which may bring on contractions again, or Pitocin, which would bring on contractions.

"But if I choose the epidural," said Fay, leaning on the bed, "wouldn't contractions slow down, and then I will need Pitocin anyway?"

"Maybe," said Katie.  "Maybe you just need to relax, that's all.  But it's possible that we will need Pitocin too."  She looked her up and down.  "See, we've been talking about this for about five minutes.  You should have had two contractions by now."

Fay stood up and started walking, rubbing her belly in small circles.  No contraction came.

"Look," Katie proceeded once she was sufficiently convinced that she would not sell the epidural.  "We can start you on the lowest dose of Pit.  We can turn it off once contractions have started again."  Again she brought up a graph.  "See, this is a woman that's already delivered.  This is her contraction pattern at 7cm, which is where you are."

"Are these Pitocin contractions?" I asked, recognizing the shape -- which looks markedly different than that of a natural contraction.

Katie checked.  "Yes, it is."  But she was not discouraged.  "But it doesn't matter," she pleaded.  "See, you should be having another contraction, right now.  I want you to have this baby vaginally.  I want to help you.  You have to let me help you.  What have you been trying?"

"We've been walking around," I said.  "Nipple stimulation.  Effleurage."

"Why did you stop the nipple stim?" Katie asked Fay.  Fay looked away.

"Walking around seemed to work too," said Simon.

"But it isn't working!" cried Katie.  "It is not working.  Fine.  What about Fentanyl.  It's a narcotic and it may help you relax a little.  We just have to get you past this hump."  Katie felt Fay's belly during a contraction.  "See, it's not very strong, either."  She sighed.  "Sometimes a mom needs some help to get over the hump.  Sometimes she just needs to relax, or a break from the pain.  Sometimes she needs Pitocin to make contractions stronger.  Sometimes the baby won't come at all, and she needs a c-section."

I winced.  Katie had made offhand c-section comments before, but I was too busy distracting Fay from the conversation to wince properly.  This time I winced.  Alluding to surgical birth to a laboring woman is akin to alluding to filet mignon to a calf.  For some women, it is a blow to her faith in herself.

Passenger, passage, and power

Contractions were coming in pairs: a big one, and a little one riding on its back.  Then seven minutes of silence.  This is called coupling, and is fine unless no progress is being made.  But if the labor is dysfunctional, which is, medically speaking, where we were heading, then it can be treated with rest (which we had done in the hour Fay slept), hydration (which we were doing), and everything Katie suggested: Pitocin, epidural, Fentanyl.

Coupling contractions can be a symptom of an occupit posterior (OP) position of the baby, or sunny-side up.  Other symptoms of an OP baby are back labor.  Which is why we had been trying so hard to get Fay's baby to turn.  Most babies, something like 70-90%,  that start out OP will eventually turn in labor.  We had hope.

Katie suggested, "We have one more thing we could try before Pit."  She left and came back with a package, a long tube inside.  "This is an intra-uterine pressure catheter.  It goes in next to baby's head in the amniotic fluid, and when you have a contraction, we measure the strength of the contraction in milligrams of mercury."
Intra-uterine pressure catheter (IUPC)

She paused to make sure we followed.  We did.

"Normal labor has three components.  The passenger, the passage, and the power.  We don't know much about the passenger.  We don't know how big she is.  Do we?"

"No, we don't," said Fay.

Katie continued: "Maybe she's malpresented.  Maybe she's facing funny down the birth canal."  She pressed her glasses up her nose, letting her blonde bangs fall into her face.  "We don't know much about the passage yet.  About the birth canal.  Maybe you aren't big enough to let the baby pass.  I don't know.  So we can try to find the power."

She held up the IUPC.  "We use this to measure the strength of the contractions.  We can use this measurement over time, over the space of several minutes and several contractions, to get an objective number called a Montevideo unit, an MVU.  If we have enough MVUs, we know that contractions are strong enough and that labor should be progressing -- and if it isn't, then one of the other things, the passenger or the passage, is stopping it.  But if we do not have enough MVUs, we can try putting you on Pit, to make the power stronger."  She paused.  "This is real, empirical evidence."
Position of intra-uterine pressure catheter (IUPC).

Now, hang on a second.  I am a newer doula, so I had not heard about the "three Ps of labor."  But I did know about the fourth P: Patience.  Sometimes it just takes time.  We had been patient, resting and walking and eating, at 7cm for three hours.  The clock was ticking since Fay's water had been broken for 16 hours.

Fay and Simon talked about it.  "Basically, our options are Pitocin, or IUPC and Pitocin," Simon concluded.  "Let's just do the Pitocin."

"Finally," Katie said.  "You are letting me help you.  I feel like I am doing something."

Fay, Simon, and Katie agreed on a dose of Fentanyl and the lowest dose of Pitocin, just to get past the hump.  Fay would still be allowed to labor upright, but intermittent monitoring was no longer an option.  Antibiotics were started because of the ruptured membranes.

Pitocin contractions were different.  They hurt more, and lasted longer, but they were not closer together.  An hour later, the dose of Pitocin was increased, and, the contractions still not any closer (though more painful), Fay asked for an epidural.

Katie started an IV, and we waited for the doctor, all the while taking one contraction at a time.

The doctor, an older man with white hair who seemed to be old enough to retire by now, came with his epidural cart and asked Fay to bend forward, achieving "the worst posture you could imagine."  He cleaned Fay's back, numbed it, and inserted the needle.

"Hmm," he said.  "Can you lean forward more?  I seem to have missed the epidural space."

I gave her a pillow to hug in her lap.

He stuck her again.  "Hmm," he said, withdrawing the needle.  "I hit the bone again," he said.  Simon's eyebrows raised, but he was quiet.

The needle went in again.  "Missed," he mumbled, perplexed.

"Look," he grumbled, having missed again, "just curl your back into a C."

Eventually, it made it in, and the pain from the contractions dispersed.  They were still coupling, so Katie increased the Pitocin.  They were still coupling.

Before she left, knowing her shift was soon over and we would not be delivering on her watch (as was secretly our plan), I asked her to transfer us to another nurse that would be patient and kind with us and try to get us back on the path of natural birth.  She said she would, but no promises.  Then, she added:

"The IUPC is your last resort, so keep it in mind."  She glanced at the door.  It was closed.  Katie lowered her voice.  "If your doctor comes in and tells you she wants to do a c-section, you ask her to try the IUPC.  Try to see if the power is sufficient, if the MVUs are enough to get the cervix opened.  Do you understand?"  We nodded.  "Good," she said, taking her leave.

A new hope

At 8pm, the sun was starting to descend outside the closed mini-blinds.  Fay drifted back to sleep, covered by a sheet and a blanket.  Simon, who still refused to sleep, and I were sitting under the window, talking about how good it was that Fay was getting rest.

A new nurse came in, introducing herself as Megan.  She was stouter than Katie, brown-haired, and was full of fresh energy.

"Hi, Megan," I said, and, meaning how Fay has been coping with labor, "we've been doing great!"

"Not really," she said, turning away from the computer with just her shoulders.  "You haven't made progress since 1pm.  Your labor has stalled."  She turned back to the computer and read the notes.

I looked at Simon and gestured that I clearly said the wrong thing.

Megan woke Fay to check her.  "Eight or 9cm," she said.

"There, that's progress," I suggested.

At this point, Simon went to take a break, and brought back food for me.  When he returned an hour later, Dr. Kim came, and Megan checked Fay's cervix in Dr. Kim's presence.

"She's a nine," said Megan.  Dr. Kim looked concerned, turning up the Pit again, and promised to check back in an hour.

The 11th hour

It was 10pm, 23 hours after Fay's water broke, when Megan and Dr. Kim returned.

"The contractions have spaced out, and they are moderate," Megan explained.  "Maybe the uterus is tired.  That can happen.  The uterus is a muscle, and muscles get tired."

Fay, Simon, and I looked at each other.  I nodded: it's true.  They do.

Dr. Kim pulled on a glove.  "Still nine," she said, withdrawing from under Fay's sheet.

"Do you know what this is?" Dr. Kim asked, holding up the IUPC that Katie described earlier.  We nodded.  "I'm going to use this to measure the strength of your contractions.  We will see what is happening."

Meanwhile, Megan took Fay's temperature and found it to be elevated.  Megan pulled the blanket away from Fay.  "You can't use this anymore," she said, and set the temperature in the room to a cool 68F.

Alone in the room with Fay and Simon, they turned to me.

"We need to talk about the possibility of a c-section," Fay said, and Simon leaned in close to me.  It was like a team meeting at a football game.  "What if they come in and offer me a c-section?  I think I should take it."

I did not reply, but listened.

"It has been a long time and I don't know if this will happen naturally.  We have been trying everything."

"We can try a few more things.  Let's see what happens," I said.  Fay and Simon nodded, and we all relaxed into the possibility.


At midnight, Fay was complete.  Megan checked with Fay's pushes: "Pushing doesn't seem to move the baby," she said.  "We'll let you labor down, meaning the baby will come down on her own."  We pushed in many different positions, despite being connected to so many machines: squatting, side-lying, legs up, legs down, back, all fours.  As Megan's hand disappeared under the sheet, she looked at me and shook her head sadly.

I was drinking a lot of soda by this point.  It was past midnight and I was tired, walking down the long hallway to the staff kitchen for more caffeine.  I ran into Megan in the hall.  She whispered to me:

"I don't know," she said, "if this baby will be coming vaginally.  Her pelvis is so small.  I can barely get my fingers inside.  I can feel the head and it's just sitting there," she made a motion with her fingers, "just sitting there on the pelvic bone."  She looked at me with sad eyes.  "Talk to them," she said, "get them ready for a conversation about a c-section."  I nodded.

Going back to the room, I did not talk to them about the possibility of a c-section, because we were already on the same page.

Five minutes later, I saw Megan rushing in from down the hall.  The machine was beeping with the baby's decelerating heart rate.  She urged Fay not to push, and we went back to the breathing we had been doing earlier.  Megan turned off the Pitocin.

"Talk to us," I said to Megan after the contraction had passed.

She looked at Fay, then at Simon.  "The baby is not moving down," she said.  "I slide my finger up by the baby's cheek," she said, showing with her fingers, "and I expect the baby to slide against my finger with each contraction.  And the baby just isn't moving down."

We sighed.

"I don't know if this baby wants to come vaginally.  I think this may have to be a surgical birth.  You have tried everything you could: I have never seen a mom spend so much time upright and out of bed.  You really have tried everything, and I have tried everything that I could think of as well."

When she left the room, I talked Fay and Simon through the procedure.  I tried to explain what Fay would feel, when she could see the baby, and where Simon would be.  Where I would be.  This hospital had a strict one-person-per-patient policy, so I could not come into the OR as I had previously done in other births.

"Will you visit us tomorrow?" Fay asked.

"I will visit you in the recovery room," I said, smiling.  "I will see you as soon as I can. I will help you breastfeed your baby."  Simon was quiet, pulling on his hospital robe and paper shower cap.  We were all so exhausted.  Simon was worried both about his baby, who was showing signs of stress in utero, and about his wife, who had been in labor for 29 hours.

I knew Fay and I had done everything we could think of to turn and move the baby.  Simon was an amazing birth partner, pressing on Fay's back with almost every contraction for over a day.  Bags under our eyes and our feet heavy with the weight of relief, we collected our items, for we would not be returning to the delivery room.

As we rolled away, Megan exclaimed, "It's a party! A birthday party!"


That's the end of the story, at least, the story as I know it.  Baby Violet was born beautifully just after 2am, and though her head came out screaming before the rest of her body was even born, and though she had spent quite some time in a meconium-rich environment (for she had pooped quite some time ago), she had not breathed any of it in.  She had a ridge crosswise on her head, rather than lengthwise where the plates of her head typically fold over each other.  She was trying to get out, but really was stuck.

Latching on to the breast in record time, Violet was perhaps the most relieved of all to be born.


Was it premonition, or did she just know, when Dr. Kim had pressed her point, with a sly smile: "Just keep your mind open for a c-section?"  Had she known that a surgical birth was necessary, she still had the kindness (to Violet and Fay) to let labor go on naturally for as long as she did.

Megan, the second nurse, on whose shift Violet was born, approached the topic of a c-section with such kindness and sensitivity to the laboring mom that I was swept off my feet.  I appreciated her acknowledgement of our hard work, of the hours we poured into the labor, and the multitude of things we tried.  I liked how she looked Fay in the eyes when she said these things with a soft voice and maternal touch on her thigh.

And, for the doulas and birth partners that read this blog: What would you have done?

1 comment:

  1. I'm a mother, not a doula or midwife. I've got 2 daughters, both born at home.

    This labour went how it went and concluded as it concluded. There is no real "do-over" point, we can respect that events as they unfolded were acceptable and can be accepted.

    However my thoughts are that the pitocin is what forced the baby down with her head in a funny position. Mama's body was slowing things down, offering her a chance to rest and baby a chance to wriggle round. The pit stopped that. The pit strengthened contractions again, pushing a malpresented baby lower until she was firmly stuck.

    I got to 41+4 with DD1, and waters ruptured at 3am with "true labour" not starting until almost 5pm. She was OP. I just pottered about, didn't summon my midwives until after midday, told them i'd talk options "after the next one" every time they tried to talk transfer. At about 4pm dd woke up inside me abd did a 180 turn in one 90second (agonising) contraction. She was born 84minutes later, with a 5minute second stage. She just neededto get lined up.

    This lesson was powerful for me - when DD2 was on her way contractions were very irregular and i could talk through them all night. 10, 15, 7, 3, 22 minutes apart. 20, 80, 25, 70, 65 seconds long. Honestly? I went to bed. I knew i'd wake if she was about to come and i knew i needed to wait this stage out. Nipple stim resulted in endless contractions, a still baby abd a sick feeling of dread so i didn't do it after the first go. Suddenly in the morning i felt pressure and called my mw. She came and a VE found the head at 0 and my cervix fully dilated. She was born 6 minutes later with a true knot in her cord and a velamentous insertion. Pit, i feel strongly, would have killed her.

    Patience in the face of the 5th p - panicky-staff, is so so hard. This birth was one which could have gone differently but not if the parents or doula had been different - if the HOSPITAL had been different.


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