Sue's second baby

Sue and I go way back -- in fact, the first birth I ever attended was the birth of her first baby.  So when she was pregnant again, there was very little discussion about whether or not I would be at her birth. Even though I had moved two hours away from her house, it was just understood that I would be there, rain or shine, night or day.

And that is exactly how it was.


Past due part deux

Five days past her due date, Sue felt her first real labor contractions. She had had contractions for months, just like with her first baby, before real labor set in. Some contractions, like the Braxton-Hicks that plagued her throughout both pregnancies, did nothing, and others opened her cervix, a little at a time.

"Why doesn't my kid like to pee in nature?" Sue lamented one morning. "I have never heard of a toddler that doesn't want to use the great outdoors. I tucked him under my arm and wedged him above my huge belly and ran with him looking for a bathroom. Contractions the rest of the day."

Three days past her due date, her OB checked her cervix at her request. "She says I have a super thin and super favorable cervix and I will go into labor for reals next time I start contracting," Sue related. "She didn't give me a number for dilation but I could tell she could get her fingers further into my business."

Of course, I gave the best advice I could: "Are you thinking what I'm thinking?" I wrote on my antique cell phone. "That's right. Mad nookie all afternoon, and baby this evening." Of course, I was not even a little bit kidding. Sex is a great way to stimulate contractions for two reasons: orgasm has been known to set off contractions (because orgasm is a type of contraction); and semen contains the same chemicals as the stuff they use to induce labor, so just letting it hang out in the vagina will help ripen the cervix. Plus all those orgasmic hormones are the same ones that course through a mom's body when she is birthing a kid and breastfeeding. Sue replied that the timing would not work out -- it would complicate the pick-up from day care for her toddler, so she decided to wait.

But she did not have to wait long: just two days later, it happened. The familiar tightening of the belly, rhythmic, every few minutes. Just like last time! That evening, Sue made dinner for the last time for her family of three. Her toddler helped her put the finishing touches on the pie, and they waited together for it to bake.  I stopped by for a while, took a look around, and read a book with the toddler. Sue said, "You can probably just go home. It will be just like last time. You know, days of early labor. I'll call you if anything happens."

I went home, and straight to bed at the early hour of 9:30pm, snuggled up with my own toddler, who was about seven months older than Sue's.


It's code for "get me some caffeine."

No calls all night. At around 8, as my kid and I were getting up, I got a message from Joe. They were at the birth center (more like a maternity hospital, because they have anaesthesiologists on site, and a surgical room) checking on the labor because the contractions went on all night. Sue slept for two minutes at a time all night long.  And on that note, I was on my way -- despite Joe's warning: "We may be sent home again." To explain -- the birth center generally practices evidence-based care, and will send a mom home if she is not in active labor, so she can labor at home without the risk of unnecessary interventions. On the road, I got the confirmation (again from Joe) that they were staying.

As I rolled into town, I messaged Joe if they wanted anything from town: coffee, breakfast?

"Soy latte please," Joe wrote. "And Sue says she would kill a man for a coffee."

"Is 'coffee' code for peppermint soy latte?" I asked.

"It is," he replied.

I walked into our neighborhood coffee house and was greeted by Jill, who remembered me from my own infant-in-arms days, well before we moved two hours away. Because I was a regular, in the shop every day for something decaffeinated.

"Hey! What can I get ya?"

"Joe and Sue are havin' a baby, so I need to pick up a couple soy lattes for them," I said. "A medium soy latte for Joe."

"No, no," she interrupted, beaming. "Joe always gets a caramel soy latte."

"Oh? He did not say caramel," I pondered. "But let's go with the usual. And a soy latte with peppermint for Sue."

"That is so exciting! I saw Sue in here the other day and she told me she was past due but it's OK because she was past due with her first baby," said Jill, "and all I heard was past due... What if she had broken her water here?"

"Nah," I replied. "Only 25% of labors start with the water breaking." I do not know why I busted out the statistics.

"That's not what happens in movies! They always swoooosh, gush all over the floor, and then there is always yelling because there's only like ten minutes to get to the hospital before the baby plops out."

We laughed, and I left with the two lattes.


Birthin'

Arriving at the birth center around half-past 10am, I delivered the two lattes to Joe and Sue, who greeted them like undergraduates after an all-nighter.  I learned that they checked in at around 4cm. Yes, it is funny to talk about time in units of measurement -- but when birthin', does time really matter? Then again, do centimeters? What really matters is how the mom and her partner(s) and the baby are doing. And here, they were doing splendidly.

Sue was standing and slow-dancing with herself during contractions, and Joe was browsing the web on his smartphone, coming over every few minutes to show off a hilarious photo -- like the one of the lemon giving birth to another lemon -- sending Sue into laugh-induced contractions. When she complained of sore feet, I asked the nurses for a labor ball. Sue sunk into the ball and moaned, "Oh yeah. That's the stuff."

Strangely, Sue had some back labor which was new to her, since her first baby did not give her such an affliction. Joe was delighted to push on her back, and was even more delighted to say obscene things about their position: her,  bending forward and him, standing behind her with his hands on her tailbone, his arms locked, his feet planted firmly into the floor, and his back against the wall.

"This position was more fun before," he remarked.

"You're telling me, kid!" Sue smirked.

Between contractions, we talked about toddlers, about mutual friends, about babies, and, of course, about labor. "I can tell this baby is bigger than the first one," Sue said. "I think this one is 9 1/2 pounds. The first one was almost 9."

"We will see!" I said.

At 5cm, or 2:20pm -- a full six hours since her 4cm cervical check -- and after a long shower, with the hot water pushing on her back (after this, the baby turned and there was no more back labor), Sue agreed to break her water. In her first birth, the AROM (artificial rupture of the membranes) sent her into full-blown labor and she had had her baby a mere five hours later. We expected similar results this time.

The OB reached the crochet-like hook inside and ruptured the membranes. "There is some meconium in the fluid," she said. "We will have to keep you on the monitor for a few more minutes."

The baby was watched for a while, but the nurses saw nothing strange; thus, Sue was released to get into the large bath tub provided she keep the wireless, waterproof monitors strapped to her belly by a wide green stretchy band. This time, there was no tub in the room, but there was one a few doors down. Sue got dressed -- the hospital gown which covered her front only, the band that covered her stomach, and a pair of gauze panties with a pad big enough to soak up a small aquarium.

We ventured into the hallway: Sue, then Joe with Sue's water bottle, and then me with the camera. A nurse from across the hall opened her eyes very wide at me and made a closing motion with her arms. I looked at Sue -- from behind, of course, and saw the problem (the behind) -- and immediately closed her gown and held it shut on our short walk down the hall.

In the warm water Sue relaxed immensely. The "ooh" and "ahh" moans were back. This time, I tried the count-up-to-ten, count-down-from-ten method that I had found to be working with my most recent clients. Her instructions were to stop me if she did not like it. She never stopped me. So I counted up to ten with each contraction, trying to match ten with the peak, and counted down as the contraction subsided.

The lights in the tub room were insanely bright. I asked the nurse if she had any of those battery-operated LED candles lying around, but she could not find them. So I did the next best thing: I taped blue washcloths over the lights with some fabric tape.

Mood lighting meets
modern engineering

Transition is when the baby falls out


An hour after getting into the tub, at 3:45pm, the telltale pressure at the top of each contraction. I called the nurse, who called the doctor, who called Sue to get her out of the water and back into the room for an exam. The nurse was the first to arrive, followed by Sue, who got on the bed and draped herself over the top of it, on all fours.

"Seven and a half," the nurse said. "Call the doctor," she shouted over her shoulder.

One more contraction, when Sue puffed like she was blowing out candles at her 3000th birthday.

"Where is the doctor?" the nurse snapped. "When I say 7 1/2 centimeters, you get the doctor," she complained with a huge fake smile and a glance at Sue and Joe to the other nurse, who had just walked in.

Sue growled.

"Hm, why don't you try just going with that feeling," said the nurse. "Just push through it."

Sue pushed.

The doctor walked in, introduced herself, and asked if she could do a little exam. Receiving the affirmative, she reached inside and whispered, "I can't find a cervix. The head is right there."

Sue whimpered.

"Why don't you get on your back," the doctor said. "It will be easier for you and the baby."

Sue turned over, graceful as any mammal with a baby hanging between their legs.

"Joe is going to count to ten, and you are going to push for the whole time," said the doctor. Joe counted; Sue pushed in silence. Then a deep breath, and more counting, more pushing, for the duration of the entire contraction. Above: Joe and Sue's heads; Joe's soft voice counting. Below: the baby's head, molded like a walnut. I snapped pictures of Joe supporting Sue. It was nearly 4pm.


But then something happened

The room filled with people: nurses for the doctor, nurses for the patient, doctor for the baby, nurses for the baby-doctor. Everyone was watching the baby's heart rate. The machine should have been beeping, but it was not. Maybe the lead was off. We had been having problems with the monitor finding the heart rate throughout the labor. The lead was off. Right?

"Let's get mom some oxygen," the doctor commanded. A plastic mask was handed to us and Joe and I placed it over Sue's face. "It's for the baby," the doctor said.

The baby-doctor, Dr. Moss, a wholly unremarkable middle-aged man in plain blue scrubs, looked concerned, with his hands folded in front of him, as he watched patiently for the baby to emerge. His two nurses were unwrapping things behind him on the baby warmer.

One more contraction, and Sue's baby boy slid out. Neither Joe nor I saw it because instantly, the cord was clamped in two places and cut in under three seconds. The baby flew in Dr. Moss' arms to the baby warmer, where six hands simultaneously rubbed a grey and floppy form of a plump infant. I put down my camera. For the first time in any of my births, I did not feel my eyes water. I felt bone dry as I came up to Sue and Joe.

"Good job," I cooed through my parched mouth. "Great job. That was so good." But nobody was paying attention. All eyes were on the baby warmer. Something white flashed in the doctor's hands -- something I have come to associate with the term "intubate" from watching TV shows like House.

There was a wet, muffled cough. Joe looked at me and whispered, "What's happening?"

"I don't know," I said.

I could see the baby's chest being massaged from both sides -- top and bottom, and his grey, limp ribcage was dancing on the warming bed. And when the ribcage danced, the grey arms bounced about on the bed as well. He looked like a lifelike doll, bouncing and dancing to some unheard music.

"He is doing fine," said the doctor. A suctioning sound came from the baby. Nobody believed him.

I looked at Sue. She was looking straight into Joe's face. The doctor was draining her placenta. Then we heard the baby's first cry, and we could all breathe again.

The nurse said, "Joe, you can go to the baby."

"I can?" he said, and, squeezing his wife's hand tenderly, and with a kiss on her head, he went to the warming bed.

The baby's head and chest had gotten pinker, but his arms and legs were still grey. Dr. Moss lifted an arm, and it snapped back into its curled place, jiggling a little.

"He is doing better, but I don't like to see babies so floppy," he said, explaining. "I want to take him to the nursery for some tests and to make sure he gets better." He used small words.

Dr. Moss was making preparations to carry the baby to the nursery. An astute nurse asked -- and for this, I thanked her silently -- "Can the mom see the baby first?"

"Oh, yes, of course," he answered and held the baby out to Sue. This gesture reminded me of The Lion King, when Rafiki the monkey presented Simba to the animals in the kingdom. Held up for the subjects, high above them and far from them, to be seen, but not touched. I watched from behind and snapped a photo: an anxious, worried, pained mother longing for her child; and the wrinkled, chubby back of a limp, pinkish grey baby.

Rafiki presenting Simba to the animal kingdom.
(c) The Walt Disney Company, 1994--1995

"Do you have any questions for me?" asked Dr. Moss.

"No," Sue said.

I looked at Sue. "Do you want to ask when you can hold the baby?"

"Yes," Sue said.

"It's hard to say," Dr. Moss said to Sue. "After we draw some blood, and run some tests. I would like to say 45 minutes. But it may take longer."

"OK."

And with this, Dr. Moss ran away with a tightly-swaddled baby. Joe went with him, and I stayed with Sue.

A blur of Dr. Moss taking away the new baby

There was so much cognitive dissonance for me. On the one hand, every doctor and nurse were saying things like "He's doing so well," but on the other, nobody could touch the baby. And he was grey and floppy. If he were doing so well, he would be on his mama's chest, just like last time. And Joe would be cutting the cord, just like last time. What did it mean? Was the baby okay, or wasn't he?

The nurse said the baby likely inhaled some meconium. I looked at the remains of the umbilical cord. It was blue, not stained by meconium the way the cords get after they had been bathing in meconium for hours. So the meconium could not have happened too long ago. What did it all mean? And why was everyone using small words and saying he was so well, when he clearly unwell?



Physical repair

Sue's doctor was threading a curved needle and began to make the repairs. "Second degree?" I asked.

"Yes," she replied.

"Ah, like last time," Sue said.

"Yes, and it looks like you tore in the same place," her doctor said. "I can see the scar right here."

It was clear that Sue was in a significant amount of discomfort. Her doctor worried: "Would you like some more numbing?"

"It's not you," Sue replied. "It's just everything. I'm very sore. Ow! OK, that one was you."

We tried to have a sense of humor, but it was so grim in the room. The doctor finished her repair, and left. Sue turned to the side, away from me, and shut her eyes. I thought she was trying to sleep after her long ordeal: twenty-six long hours of early labor, and an hour and a half of the real deal. And then this.

I touched her thigh. "Do you mind if I go to the nursery and try to get some pictures of the baby? I have my phone. Call if you want me to come back."

Sue nodded, eyes shut. I went out.


Nursery

The nursery was a single room, attached to a the single operating room. Outside the nursery door, I saw through the mostly-closed blinds that inside, there were just two warming beds. Only one was occupied, with Joe and Sue's baby. Joe was rocking in the chair nearby and two nurses and Dr. Moss were doing something to the baby. A third nurse was at the computer, typing furiously.

I do not know what I was imagining a nursery to look like. Maybe like nurseries in the older movies, with a row of beds and a baby in each bed, and a large window to see in. This was a far cry from that image, and there was significantly less cooing over new babies.

A nurse approached the door and I asked her if I could go in.

"Are you family?" she asked.

"No, I am a friend," I replied. "I am Joe's friend. He is inside on the rocking chair."

"I will ask," she said, and disappeared inside. I stood back and read some things posted on the bulletin board while I waited. There was an article about a woman that had a c-section, and someone had left a surgical sponge inside her abdomen. The sponge caused several of her organs to fuse, and the court granted her over $500k in medical expenses, and the nurses were held responsible because they should have counted the sponges. They said they did, and it should be the doctor's fault because he was in charge.

The nurse returned and said that I could not come in because they were going to clear the room for a chest x-ray, to check whether there was any infection in the lungs from inhaling meconium. I thanked her (for what?) and headed back to Sue's room.

In the small waiting area, I met a white-haired woman wearing nice exercise clothes. I had seen her waiting, talking on the phone, and reading books on those couches several times in the hours since I arrived. I asked: "Having a baby?"

"Well, I hope so. We have been here all morning and things are happening very slowly. How about you?"

"My friend had a baby boy recently."

"Oh, how lovely! There was a baby boy born at 3, is that your friend's?"

"No, hers was at 4."

"Oh, two baby boys! How nice. Is he with your friend now?"

"No, he's in the nursery."

Her eyes lit up. "There is a nursery? Where you can see the babies?"

"Um." I did not know how to answer that question. I could have said, "It's where the sick babies go." Although not untrue and not really revealing anything about Sue's baby's condition, I did not know if it would be the wrong thing to say. Instead I said, "No, you can't see in, and there is just the one baby inside."

Sue's nurse came out of her room. Seeing me she said, "Can you do me a favor? Do you know where the baby blankets are?"

I confessed I did not. She explained where to find them, and that underneath the warm baby blankets are the warm adult blankets. Sue was cold. I rushed off.

In the room I found a frightened Sue. She had not been sleeping -- she had been terrified. I put the toasty blanket on her and sat by her head.

"I thought you were sleeping," I said. The room was dark, and the rain spattered on the window and the small balcony outside. Sue's room was silent and lonely.

"No," she replied. After a pause: "Everything hurts." And: "I want my baby."

"I know. Joe is with him. I was watching him watching your baby."


Emotional repair

Hours passed without any of us really understanding what was happening. The turning point was when the nurse suggested a trip to the nursery. This motivated Sue so much that she immediately forgot about her body's aches; with her nurse's help she got up, got dressed, and was wheeled in the chair to the nursery.

Joe was standing up over the warming bed with a finger in the baby's mouth. The baby was sucking beautifully. Joe said: "My finger is all pruny. This has been going on for hours. My feet are sore." We laughed. Finally, we laughed.

The baby was connected to a heart monitor, oxygen saturation sensor, breathing monitor, and an IV in his ankle, and the nurse was trying desperately to draw blood from any of the baby's four limbs, with little success. She had been trying for quite some time. With each needle-stick, the baby would cry briefly, and continue sucking.

"Do we have any sugar-water?" another nurse asked. "If you put some on your finger for him to suck, it's a natural pain reliever for the baby."

"How about we use breast milk?" I suggested, always the advocate.

"I'm not sure there is any in there," Sue said.

"That is a great idea," the nurses said, and gaily approached Sue. "Try it!" Sue tried expressing a little milk onto Joe's pinky and out came a copious amount of colostrum. And as soon as Joe put the finger into the baby's mouth, his eyes opened and he visibly salivated.

"He likes it!" everyone exclaimed.

Sue finally got to hold her baby, still connected to all of his tubes and monitors, at 7:30 -- over 3 1/2 hours after his birth. She held him and nursed him, though he was already drifting into a solid sleep. But in his sleep he would wake, nurse, and fall asleep again, snuggled skin-to-skin with his mama.


Conclusion

Every birth is different. How true this is.

Sue's goals for this labor were to complain less and to push faster, and she succeeded in both. She complained very little -- only in transition did a little complaint escape her lips (and who wouldn't, a little?) -- and she pushed for just fifteen minutes. One could say it was a better birth in this way.

But after the baby's birth, when things took a turn for the unknown, when the baby did not go directly on mama's chest but was instead whisked away, and nobody understood what was happening -- oh! how different it was than the first, picture-perfect natural birth.

You will hear, "What matters is a healthy mama and a healthy baby." While this is true, it is an understatement to the emotional roller coaster which is made more prominent by the mother's extreme hormone shifts after the birth of a baby. In the end, this story had a happy ending, though certainly not without serious worry.

What really happened? I guess this is something for Joe and Sue to figure out with their doctor. My part is to support them throughout birth, and my support will continue until they have closure.

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 --

Gush!

"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.


Crying

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.


Complete

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!"


Postpartum

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.


Foreshadowing?

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?

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.

My midwife failed me: How homebirth transfer affects mothers

Homebirths account for just a small percentage of all births in the US: 0.59% of births happen at home. Interestingly, this number increased by 5% between 1990 and 2005, which we could call a surge in homebirths [1]!

Besides homebirths being more satisfying for women [7], one of the main reasons some women choose a planned homebirth over a hospital-based delivery is because both mothers and babies have better outcomes. The cesarean section rate in homebirths is around 4%, compared to over 30% nationwide [4]. Mothers have fewer interventions, including episiotomy (a surgical cut to open the vagina), and babies die less often [2].

There is no way to sugar-coat that. Babies born at home die less often -- because of the lack of unnecessary interventions. One meta-analysis found that the neonatal mortality rate tripled in planned homebirths versus hospital births, and attributed the better outcomes for babies to the decrease in interventions [2].

Not all mothers that plan to deliver at home end up doing so. For a variety of reasons, a transfer to a hospital may be necessary or preferable during or after childbirth. Sometimes the reason for transfer is maternal exhaustion -- labor takes a very long time and the mother is too tired to go on. Sometimes there are negative health signs with the baby -- heart rate decelerations, or meconium in the amniotic fluid. Rarely, the transfer is caused by something more grave. Usually, the decision to transfer from the home to the hospital rests on the midwife. In the US, the transfer rate is around 12.1% [4].

But how does a woman, who planned to deliver at home, who spent months preparing for her natural birth within the safety and comfort of her home, who anticipated an intimate experience, feel about a transfer to a hospital? Anecdotal evidence hints that something is missing from the birth experience. Does the mother blame herself for failing to deliver a baby at home? Does the blame later shift to her midwife, for letting her down? Is she grateful for being able to spend even part of her labor at home [6]?

We turn to science for an answer.

Is homebirth transfer traumatic?

Let's take a look at the Netherlands, where the homebirth rate is much higher than the US: In one study, over 38% of first-time moms and 67% of repeat mothers delivered at home (recall that the US average has risen to under 1%) [3]. For the first-time moms, 40% of the planned homebirths ended up transferring to the hospital at some point during birth or shortly thereafter; and 11% of repeat moms transferred to the hospital (compared to 12.1% of home-birthing mothers in the US, both first-time and otherwise). The Netherlands data is summarized in the table below.

	First-time mother	Repeat mother
Planned homebirth	38%	67%
Transfer to hospital	40%	11%

The women in this study rated their birth experience, their midwife, and their immediate postpartum days by marking agreement with specific adjectives on a five-point scale (where 1 is strongly agree and 5 is strongly disagree). The conclusion from this study?

Our research showed, contrary to expectations, that an unplanned transfer from a planned home birth to hospital has little influence on the experience of childbirth [3].

Let's look at Sweden.

In Sweden, homebirths are rare -- as rare as in the US -- that is, less than 0.1%.  In Lindgren, et al.'s study [5], the homebirth transfer rate was 25% for first-time mothers -- that is, one in four women that plan a homebirth end up in the hospital (much better than the 40% rate in the Netherlands). The most common reasons women transfer to the hospital are "lack of progress" and (this was surprising to me) the midwife being unavailable for the mother during labor.

The exciting conclusion in Sweden:

Being transferred during a planned home birth negatively affects the birth experience [5].

Looking elsewhere, we find agreement:

Women who are referred to the hospital while planning for a home birth are less satisfied than women who planned to give birth in hospital and did. A referral has a greater negative impact on satisfaction for Dutch women [than for Belgian women] [7].

In fact, the Swedish study found that women really hated and resented their homebirth transfer experiences, as visualized (by me, from Lindgren's data) by the graphs shown below in Figure 1 and Figure 2.  In these graphs, the blue line indicates a "very satisfied" response and the red line is anything less than "very satisfied." The thing to take away from these graphs is the area inside the red line. A large red area is bad. In the homebirth without transfer case, you can see that women were more likely to be "very satisfied" with all aspects of their birth (except for being in control -- but can you really control birth?).  In the homebirth transfer case, women were more likely to be less than satisfied with everything except partner support and the midwife making the partner involved.

Figure 1. Satisfaction among Swedish women regarding their homebirth experience [5].

Figure 2. Satisfaction among Swedish women that planned a homebirth but transferred to the hospital during or as a consequence of childbirth [5].

Homebirth: Forbidden fruit


Could it be, then, that in places where homebirth is rare, women place undue emphasis on the location of birth? Could it be that birthing at home becomes kind of a holy grail that women strive for?  It is so rare in the US and Sweden that it is like a forbidden fruit. We hear and read so much about its beauty that we -- that is, those women that yearn for homebirth -- strive for it and are crushed when we do not get it.

Consider another birth outcome some women consider traumatic: the cesarean section. One thing that childbirth educators did to make the prevalence of the c-section more palatable and less scary is to demystify it. In childbirth education classes, c-section is presented as a possible birth outcome -- a real possibility. In a good prenatal education class, analgesia, surgical procedures, and postpartum recovery will be discussed in detail. When you think about it, this is a really good idea, because one in three people in the classroom will have this surgery, whether or not they planned for it.

It may be that one of the things that makes homebirth transfer an emotionally crushing outcome is that it is still an unknown evil. So why not demystify the homebirth transfer? Describe it in detail for women and their birth partners to take in: causes, procedures, outcomes. The Wiegers study made this interesting note:

It seems more important ... to reduce the fear of unplanned [homebirth to hospital] transfer, especially among nulliparas, than to advise women to choose a hospital birth in order to avoid such transfer [3].

Interesting because this is the only study that I found that did not result in negative emotions in the mothers resulting from homebirth transfer. Maybe in the Netherlands they drill the transfer as much as we (ought to) drill the c-section?

Lindgren had a different conclusion:

Treatments as well as organizational factors are considered to be obstacles for a positive birth experience when transfer is needed. Established links between the home birth setting and the hospital might enhance the opportunity for a positive birth experience irrespective of where the birth is completed [5].

In fact, in the Sweden study, one of the main reasons women were unhappy with the hospital setting was because everyone was so dang mean to them -- possibly for choosing a homebirth to begin with. They found that doctors -- obstetricians, general practice physicians -- simply do not understand what a midwife does in the home and why she should continue to be useful even after a transfer. Maybe the homebirth transfer education should start with the hospital.

Did my midwife fail me?

I do not know. But I do know that everywhere around the world where homebirth is rare, homebirth transfer to a hospital carries with it a negative weight. In the Sweden study, half of the women that underwent homebirth transfer were less than satisfied with their midwife's support, compared to over three-fourths (76%) of those that stayed home. Not surprising when you consider that the #2 reason for transfer is because the midwife simply could not come to the birth [5].

Conclusion

There are three ways to fix the problem of the negative affect of homebirth transfer.

1. Teach hospital staff about homebirth transfers. Drill it, demystify it. Emphasize that a transfer is not the mother's fault; it is not the midwife's fault. These things just happen.
2. Teach mothers that plan for homebirth about homebirth transfer. I mean, really drill it.  It is a real possibility and a mother should know the routine. Drill it, demystify it. Encourage that a transfer is not her fault.
3. Encourage homebirths. There is reason to believe that, when the overall percentage of women that plan for a homebirth is large, a transfer to the hospital is no big deal -- possibly because the hospital staff know what to expect from a woman and her support team, and how to best help.

Given our surge in national homebirth rates (still under 1%, but we do our best), you would think we would be quick to implement these items.


References


[1] United Press International (2010). US Homebirths Few, But on the Rise.  Retrieved 4/24/11.
[2] Wax JR, Lucas FL, Lamont M, et al. (2010) Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis. Am J Obstet Gynecol 2010;203:243.e1-8.

[3] T. A. Wiegers, J. van der Zee, and M. J. N. C. Keirse (2001). Transfer from Home to Hospital: What Is Its Effect on the Experience of Childbirth? Birth, 25 (1).
[4] A. Haas (2008), Homebirth After Cesarean. Midwifery Today.

[5] H.E. Lindgren, I.J. Rådestad, and I. M. Hildingsson (2011). Transfer in planned home births in Sweden – effects on the experience of birth: A nationwide population-based study. Elsevier 2011.
[6] J. Davies, E. Hey, W. Reid, G. Young (1996).  Prospective regional study of planned home births. BMJ 1996.
[7] W. Christiaens, A. Gouwy and P. Bracke (2007). Does a referral from home to hospital affect satisfaction with childbirth? A cross-national comparison. BMC Health Services Research 2007.

Surprise birth during a doula interview!

Hey! I thought when I received the friend request on Facebook. I haven't heard from Mia in years! I wonder what she's up to.

I scrolled over to her photos and found she was very, very pregnant.  How lovely! I posted on her wall. Almost immediately she replied: Did I read that you are a birth doula?

We chatted over Skype a few days later.  "Do you really want me at your birth?" I asked.  She grinned into the webcam and gave the double thumbs up.  We decided we would have our first prenatal visit on that Saturday, just five days later, when she would be at 38 1/2 weeks pregnant with her baby girl.  We would discuss her preferences for the birth, I would meet her partner, Henry, and the three of us would read over my contract.

Saturday rolled around and I hopped on a train in the morning to go into the city to their central apartment, leaving my son in the care of my mother and my husband.  I brought nothing with me but my positive attitude and a can of iced coffee.  I looked out the window and thought about how exciting it was to be reconnecting with an old friend, and going to a doula interview.

My phone buzzed with a text message from Mia: "These contractions are different," she wrote -- not like the Braxton-Hicks contractions she had been feeling for the last several days.  Different how? I texted back.  She described them as achy, spreading from her belly into her back and hips.  "Like menstrual cramps," she wrote.

Huh, I thought, How curious.  I considered how she messaged me two nights ago saying she was filling her freezer with food, and later that she spent all morning cleaning and rearranging her apartment.

I arrived at the train station, where Mia was waiting beside her dusty, grey car, wearing a stretchy dress.  She was just as I last saw her: very tall and very skinny, with curly dark hair and cute, small glasses, but with a basketball tucked in her sweater.  I ran up and hugged her, scolding jovially: "Are you in labor?"

"Maybe!" she exclaimed.

This could last all night

We hopped in the car and tried to catch up while I drove.  She rattled off directions.  It was hard for both of us to conceal our excitement.  Then she hesitated.

"Ah, a contraction," she said.  "I'm going to try to talk through it, just to show that I can." And she continued her story about how she and Henry went to the movies the night before.

No problem, I thought.  Early labor.  This could last all night.  

"So did you know?" I asked. "That you'd go into labor today?"

"Oh yeah," she said, "I knew. Henry didn't, but I knew."

In Henry's one-bedroom apartment that they shared, we got ready to go to breakfast.  During contractions Mia would roll her eyes, take a long breath, and pace the living room.  I texted my family: Mia in early labor. Maybe tonight, maybe tomorrow night. Staying here.

The three of us took a slow stroll to a nearby restaurant, on top of a beautiful, tall building with flowers and trees growing on the roof.  Eastern drum-beats played over the speakers and I thought of belly-dancers with bells around their ankles.  We were seated in low armchairs surrounded with pillows in front of a copper table.  Mia, sitting on a towel just in case, ordered a hearty breakfast.  By this time, during contractions, she would stop what she was doing and concentrate inwardly, breathing deeply with eyes shut loosely.

The waiter approached us with our food and looked concerned.  After a contraction, he smiled and said, with a light Persian accent, "You aren't going to have the baby right here, are you?"

"No, no," Mia replied, smiling. "It will be a while."

With this public acknowledgement, suddenly, I became energized.  Everything was tingly, exciting, colorful, happy.  We were going to have a baby!  Other patrons of the restaurant turned to us and smiled encouragingly; I beamed back.  Henry beamed, touching Mia tenderly on the knee.  We were supposed to discuss business, but it never happened: we were too excited that this was all happening!

We ate our breakfasts gaily.  Every few minutes Mia would put her plate down, lean back in her low chair, and exhale.  After the contraction, she would bring her plate back up to her belly and use it as a shelf.

On our walk back to the apartment, Mia sat during contractions on the benches we passed, but noted that walking felt better.  However, as we approached home, she mentioned she would rather not be around other people.  Aha! A clue about our labor progress: in active labor, women prefer to be in a safe place with fewer distractions and no strangers.  There is a hormone released that can actually slow down or stop labor when women feel threatened.  It is part of the fight-or-flight response.

Meanwhile, my husband was coming up by train to drop off my doula bag with some overnight necessities.  With Mia and Henry's blessing, I parted ways for about 15 minutes as I ran to meet my husband half-way between the apartment and the train station.  

When I returned, red suitcase in hand, to the apartment, Mia was on the phone, calling friends are relatives and checking in with her doctor, to let the hospital know we would be coming within the day.  "Henry and I are in labor," she would say.  Then: "I need to call you back." She would hang up the phone, breathe through a contraction, and call again. "It is hard to talk through those," she explained to the person on the other end.

I thought it would be a good time to talk about drugs in labor, because we never did that.

"Do you want to pick a safe-word?" I suggested.  A safe-word is a secret word that we choose in advance that means I really want medical pain relief.  "Sometimes, women may say they want drugs, but what they mean is that they want more support," I said.  "Sometimes women want more support when they're scared, and they ask for drugs."

"No safe-word," Mia said.  "I'm not scared.  I just don't want to be in pain."

"There is a line between pain and suffering.  Pain is expected, and it is good.  But we don't want you to suffer."

Mia took a long shower.  Then, Mia said she was tired.  Still thinking there was plenty of time and that this was fairly early in the labor, I suggested she take a nap and mentioned -- you know, by the way -- that intercourse was likely to speed things along.  Henry looked at me like I was crazy.  Mia disappeared with Henry into the bedroom and I waited in the living room, listening for sounds of difficult labor and hearing none.

Undressed

About an hour later, Mia re-emerged, naked.  I thought: The apartment is very hot. That is why she is naked.  One midwife once said that you can tell how far along in labor a mother is by where the sheets are.  If the sheets are pulled up to her chin, she is in early labor. If the sheets are at her waist, she is in active labor.  If the sheets are missing, she is in the second (pushing) stage.  We were certainly nowhere near the pushing stage, but the lack of clothing was a sure sign.

From here on, Mia's bowels moved every half hour and contractions were about five minutes apart, but some lasted only 30 seconds and some were longer.  Playing it down, I said, "Your uterus is finding a nice pattern, and you are likely entering active labor."  Turning to Henry, after a particularly long contraction (about a minute and a quarter) that required a lot more concentration, I added: "That is what active labor contractions look like. We want them to look like that."  Mia leaned forward over the bathroom sink and danced slowly from foot to foot while I counted in rhythm with her dance.

Mia came out of the bathroom saying,  "I am certainly in an altered state now."  An altered perception of time is common in active labor.

I grinned, proud of our accomplishment. "Do you know what time it is?"

Mia thought.  "Maybe five?"

Henry looked at his phone.  "Six," he said.

In our postpartum meeting, Mia pointed out that it was not just an altered perception of time, but an altered state of consciousness that she felt at this point.  "In one of our classes," she said, "we were told about early labor task. We were told about a woman (an author, I think) who monitored her state of consciousness for change between early and active labor by baking cakes. Making a cake requires one to read a recipe and measure amounts carefully. In active labor, it is not possible to do anything accurately. The will and perhaps even the ability to focus on a multi-step task just goes away."

What about massage, stroking, and other physical comfort measures in labor?  Twice, Henry tried to stroke her on the shoulder, or would touch her curly hair in a loving gesture.  Mia's response was unilateral: "No touching."

Smiling, I turned to concerned Henry and said, when Mia was out of earshot: "Totally normal."

A few hours passed in this way: We counted through contractions: ten counts up, nine counts down.  Mia changed positions from the toilet to slow-dancing with Henry to leaning over a chair to leaning back on the coffee table from an ottoman.  She looked so beautiful -- her round belly illuminated by the sunlight filtering through the closed shades, as she rocked back and forth or danced from foot to foot. Her head rolled on loose shoulders.  She visualized waves breaking over her body.

With each contraction, Mia announced: "Start!"  Henry dutifully pressed the start button on his contraction logger app on his mobile phone.  Then, she would breathe and roll her eyes and dance, exhaling the contraction.  "Stop," she would announce.  Henry would mark the end of the contraction. In my opinion, the contraction app was a blessing: it kept Henry busy and made him feel like he was performing an important role in labor.  During contractions, his focus was on Mia, but between, he could mentally calculate averages and cross-reference them with his knowledge of labor.

On the toilet, mucus and water came out.  "I think this is my mucus plug?" Mia said, examining the toilet paper.  "Sure," I nodded.  But we were far past the mucus plug, even though when I checked Henry's meticulous log, I saw that contractions were 4 minutes apart but rarely over a minute long.  In fact, most were between 40 and 60 seconds long.  When we talked about this discrepancy postpartum, Mia explained: she did not announce the beginning of the contraction, but when the real discomfort began; similarly, she announced when the discomfort stopped, not when the tightness eased.  Henry and I should have mentally added 10 to 20 seconds to each measurement! 

Surprise at the hospital

Henry called the hospital.  During the phone call, I took the phone from Henry during a contraction and talked to the nurse.

"First contraction happened at eleven this morning," I said.

"Has she been keeping hydrated? Is she resting?" the nurse asked.

"Yes," I replied, "a sip of water after every contraction. She had a good breakfast and a nap in early labor.  We've been in active labor for, hmm, maybe an hour?"  Even as those words escaped my lips I knew it had been longer than an hour.  But I did not offer a correction.

There was a pause. Then: "OK, you'd better come in."

"We may be a while," I said as I looked at Mia, totally naked, draped over Henry.

"That's OK," the nurse replied.  "We will have a room for you."

And so we started getting things together.  The car was already packed; we just needed last-minute things: camera, charger, phone, charger, Mia's earrings that she removed earlier -- oh, and clothes for Mia.  Because she was still naked.

"I'll wear my grey stretchy dress," she said.  "It is really stretchy."

She waited patiently in the bathroom while Henry rifled through her drawers, bringing grey things that weren't dresses or dresses that weren't grey, until finally, he found the right dress.  Mia started pulling it on.  I tried to smooth a wrinkle.  "No touching!"

She put on panties with a maxi-pad, green slippers, and waddled to the door.  We went downstairs to the parking garage and waited by the car for a contraction to pass.

"Henry, sit behind me; Mia in the front; I drive," I said.  "Go! Go! Go!"

Mia spoke directions in the same voice as this morning, but a little more distant.  Outside, the sun was setting over the city in a beautiful red, pink, and purple sunset.  A contraction started.

"It's OK to pull over," Mia said.  "Just double park."  I did that and counted.  Up to ten, down to one.  We continued, pulling over twice more.

Mia said: "I will want an epidural when we get there.  I have been enduring this long enough."

"Let's see where we're at in the labor," I suggested.  "After they check you, we'll see. OK?"

Arriving, I helped Mia out of the car, and let Henry take her inside while I parked in the garage.  We had considered parking all together and walking in ("the walk would be good for you," I said) but it did not seem possible anymore.  How far along were we?  I had no idea.  I gathered our things (three bags) and ran to the main hospital entrance where I dropped off Henry and Mia.  To my chagrin, it was closed -- that entrance closes at 8 o'clock, and it was exactly that.  A pizza guy was standing outside the main entrance as well, looking confused.  I greeted him, turned, and ran up the hill to the emergency entrance.  Her last contraction, Mia puffed at the peak and then mentioned some pressure.  Pressure means pushing.  Could we really be that far along?  I imagined her and Henry walking toward the entrance, stopping for a contraction, and the baby suddenly being born, right there on the sidewalk.

I signed in to the visitor log, with the pizza guy right behind me.  The emergency waiting room perked up with the smell.  I ran down the hall, waited hours for the elevator, and finally arrived at Labor and Delivery, where I had to sign in again.  I saw that Mia and Henry signed in just five minutes before me -- good sign, it means the baby was not born on the sidewalk or in the corridor as I feared.

Mia was in the tiny triage room with Henry and a nurse, on the bed, still pregnant, with the fetal monitor strapped to her belly as the nurse tried to find the heart beat.  For a while, there was nothing.  I held my breath.  Where was the baby?  Was she OK?  Then, she found her: low.  She breathed through another contraction as I counted.  At each contraction, the nurse paused what she was doing and waited.  How nice, I thought. A nurse that knows how to let a woman labor.

"Have your waters broken?" asked the nurse between contractions.

"I think so," said Mia.  "There was a trickle."

The nurse explained that there does not have to be a gush: sometimes when the waters break on top, there can be a trickle as they leak around the amniotic sac and out the cervix.  When they break on the bottom, you get a gush; then, the baby's head presses against the cervix and stops the flow.

The nurse said, "I'll let the doctor check you once we get you a room, since your waters may have broken.  I don't want to increase the chance of infection."

After the next contraction (she puffed at the peak again, quick in-out-in-out breaths), she turned to me and Henry and said, "Pressure again."

I looked at the nurse, who did not seem to hear.  "Mia says there was some pressure," I said, emphasizing the word.  "Pressure."

"Perhaps I had better check you now," she said.  All eyes turned to her as her hand disappeared between Mia's legs and the blanket.  Her eyes widened.

Grinning, she said: "You're not going to believe this.  Guess!  Guess how far you are!"

Mentally, I guessed as from under the sheets escaped the smell of transition.  It is a peculiar, memorable smell.

Getting no reply, the nurse continued: "You're a nine.  Nine and a half!  There's just a little lip.  Zero station, meaning the baby's head is right up against your public bone."  Holy crap!  Henry's eyes widened.  I had no idea.  Mia's contractions were short, she had never vocalized, and she looked so natural and calm!

"Can I have an epidural now?" Mia asked, not amused.

"Honey, there's no need," said the nurse.  "Look at you! You are doing so well! By the time we get the doctor in here, and the epidural to take full effect," she gestured a circle with her arm, "the baby will be born!"

I suggested, "The contractions aren't going to get any worse."

The nurse continued: "That's right, and it will feel so good to push against all that pressure."

One more contraction.  Breathing, puffing, as the nurse struggled to find an empty room for us.  We were not even in the computer.  Nurses started coming in and out, introducing themselves to Mia in loud, even voices.  One nurse started a hep-lock (IV with nothing going into it).  One checked again: Mia was complete.

But the orders were to puff, not push.

Eventually, we were all transported into the operating room because, unbelievably, that was the only room available where we could deliver a baby.  Henry and I dressed in white paper jump-suits and white fluffy shower-caps and shoe-covers, and Mia was instructed to hop (hop?!) from the triage room bed to the operating room birthing bed.  A tall order for a lady pushing out a baby, but she did it with grace.

Birth

As soon as we arrived in the operating room -- large, round lights overhead and little carts of equipment everywhere -- I asked: "Can we push now?"  The nurses beamed and nodded.  "You sure can!" I turned to Mia.

Without instruction, without anyone yelling at her to push, without anyone coaching her to make a C with her spine and pull her knees to her chest and hold her breath and count to ten and wait for a contraction, Mia pushed in a raised position on the hospital bed, hands on her thighs.  And those were some mighty pushes.

Her water finally broke in earnest, spraying eight feet down the bed and narrowly missing the nurse.  We laughed; a lock of the baby's hair was seen.

To Henry, I said: "Want to see?"  He shook his head, but after a little more coaxing, he glanced, white knuckles hanging on with all their might to the side of the hospital bed.  He looked pale, and stroked the pillow above Mia's head with his thumb, looking gently at her forehead.

"She has curly black hair, just like you," I said to Mia.  "And it's long.  Reach down and touch her." With long, slender fingers, Mia stroked the top of her baby's head gently, until another contraction came.  The head was at the perineum.

"You have to get past this," I said as Mia squirmed her hips side to side.  "You have to go through it."  I hope I sounded brave.  I really wanted to sound brave.  It is hard to tell a woman to do something clearly painful, something contrary to what the body says: to push into the pain and the burning on the perineum.  Henry clung to the bed; a nurse poured mineral oil on the baby's head to lubricate the exit.

In two more contractions, just an hour and a half after our arrival at the hospital, baby Cathy was born in the operating room, in what was one of two natural births in the hospital that day (usually they have one every other day or so).  Cathy cried on Mia's chest as nurses rubbed her pink body; pale, Henry cut the cord, signifying the entrance into the world of his baby girl.  Against Mia's skin, baby Cathy was visibly calmer, though still bewildered.  Mia shielded Cathy's eyes from the harsh operating room lights and cooed: "I know, baby, I know -- it's so bright in here."

Postpartum

In the recovery room (which was actually a labor room -- all of the recovery rooms were still busy for the next hour or so), Mia breastfed her newborn for an uninterrupted two hours.  The nurses waited until Cathy was full to do the usual weights and measurements.

While breastfeeding, Mia turned to Henry and me with glistening, happy, tired eyes and said, with her mouth watering: "Oh, man -- we should order a pizza. A deep dish pizza. Doesn't that sound so good?"

Conclusion

That was the best doula interview I had ever had.