Thursday, June 9, 2011

Pregnancy #1 Giana's Birth

At a routine office visit at 38.5 weeks gestation Karen, a Certified Nurse Midwives in my obstetric clinic, announced that the protein traces in my urine sample were alarmingly high. She feared that my pre-eclampsia state might worsen and develop into eclampsia which is potentially fatal. Eclampsia is characterized by blurred vision, and blood pressures high enough to induce seizures.

Karen sent me to the hospital for non-stress testing with the on call midwife. In the Labor and Delivery unit, Claudia decided to induce labor using Prepidil Prostaglandin E2 Gel; which is a prescription prostaglandin ointment that is applied directly on the Cervix. The presence of prostaglandins in the gel soften and thin the cervix, otherwise known as ripening.

At the end of the ripening period contractions occur. Sometimes they are not strong enough to induce labor on their own and require a follow up of Pitocin IV Administration. At the time I knew that Pitocin could cause strong, erratic contractions resulting in hyperstimulation of the uterus, but I did not know that Prepidil Gel could do likewise. Pitocin IV Administration is the most common form of induction, it may also be referred to as Oxytocin or Pit.

In addition to applying the Prepidil Gel, Claudia stripped my membranes. The stripping or sweeping of membranes involves the provider inserting a finger into the cervix and lifting the amniotic sac of the cervix with a stirring motion. This process irritates or triggers the local release of additional prostaglandins. Additional prostaglandins intensify the ripening of the cervix. The stripping of membranes can be moderately to extremely uncomfortable. It requires that you be at least 2 centimeters dilated and usually results in bloody show or the presence of blood on the caregivers’ fingers.

In my case the contractions began immediately with abdominal cramping similar to menstrual cramps. Claudia instructed me to report back to the hospital for a second dose or application if labor hadn’t initiated within four hours.

I left the hospital optimistic about my body’s ability to perform its proper functions. My husband, Neil, and I went walking, hiking, riding over bumpy roads, etc. Labor was not imminent.

Four hours later we reported back to Claudia in the Labor & Delivery unit. I wasn’t feeling very hopeful that a second dose would prove much more effective.

Claudia applied a second dose and once again stripped my membranes. At this point I should mention that it’s very important to avoid using the bathroom for at least 15 minutes after applying the Prepidil Gel as it is very expensive and needs time to sit on the cervix for maximum efficacy.

Two minutes later. My bowels cramped and I announced, “Claudia, I have to use the bathroom.”
“Is there any possibility you can wait?” she asked.

Cringing, I shook my head.

Claudia sighed, “Okay, do what you have to do.”

I barely made it to the bathroom in time for my bowels to empty what seemed like their entire contents. I sat on that toilet for at least 30 minutes before I dared to stand again.

I changed out of my gown preparing to go home. Claudia informed us that if labor didn’t initiate by seven o’ clock the following morning I needed to return to the Labor and Delivery unit for a Pitocin IV induction.

As Neil drove me home my back ached, my stomach cramped and my swollen appendages throbbed. I headed for the bath tub where I soaked for an hour. My back pain intensified so much that I could no longer stand the pressure of the hard tub against my spine.
Neil lounged on the couch watching an NBA game and I retired to bed.

I curled up in a ball lying on my left side. I felt completely exhausted but I couldn’t sleep. My back hurt so badly and no matter what position I tried I couldn’t seem to relieve it. I tossed and turned for a couple of hours.

Eventually Neil entered the dark room and joined me in bed. We both lay there in silence for what seemed like an eternity. Labor tends to distort our perception of time, which is why I highly recommend keeping a watch on you.

Sometime after midnight I queried, “Neil are you awake?”

“Yeah.” He mumbled as though he were really in a deep sleep.

“I need help. My back hurts so badly. I don’t know what’s wrong with me. Will you please call Claudia?”

Neil climbed out of bed and punched the previously programmed number on the phone. I carefully crawled out of my side of the bed and rocked myself back and forth on hands and knees. I leaned all the way forward resting my head between my elbows desperately working toward some sort of relief.

Then it came…relief. Sweet relief! I experienced a full 45 seconds of relief.

Suddenly the pain gripped me again growing stronger until I thought I couldn’t bare it any longer. I felt nausea sweep over me. “I’m going to throw-up, Neil. I need a bowl.”

This pain was NOT natural! It felt like something was very wrong. In retrospect it seems I experienced a bit of uterine hyper stimulation. I never again in any subsequent pregnancy experienced any sensations as severe as those endured in this labor.

Neil ran to the kitchen and grabbed a plastic bowl in the midst of describing my behavior to Claudia. He handed me the bowl and asked, “Claudia wants to know if the back pain is wrapping around toward the front of your uterus?”

We’d been taught in our prenatal class that you should go to the hospital when your contractions were 3-5 minutes apart. But they also described uterine contractions as a tightening or cramping of the muscles surrounding the abdominal area. This certainly did not fit that description.

I shook my head, “I don’t know. My back pain is so intense it’s overpowering all my other senses. I noticed that it stops hurting for a little bit so I started timing it. If this back pain is labor than the timing from the beginning of one contraction to the start of the next is about 2 minutes apart.”

Neil relayed the message into the phone. Then he nodded his head and said, “Yeah, she normally demonstrates a high pain tolerance. Okay, okay, yeah, okay. See you in a little bit.”

He turned off the phone and directed me, “She wants us to meet her at the hospital right away.”

I released a dull groan as I tried to raise myself to a kneeling position. When I moved one leg forward to get upright my water instantly burst. Nothing could have prepared me for the volume of the gush.

Our childbirth instructor taught us that when the water breaks or membranes rupture it’s like peeing your pants. A steady stream of clear fluid flows from the vagina, only you can’t stop it. What I didn’t know at the time that her description only applied to a high amniotic rupture. A low rupture produces a much more forceful splash. It was like having 10” water balloon pop between my legs. Along with the clear fluid a blood clot the size of a Kiwi dropped and that’s when I lost my calm.

“Neil what just happened? That’s not supposed to happen.” I looked to Neil for clarification. His eyes gave way to his own panic. Everything seemed out of my control. My body went rigid with fear. I stopped breathing deep, calm, oxygenating breaths and resorted to shallow fearful pants.

We hurried to the car with our previously packed hospital bag but forgot the plastic bowl. During our fifteen minute drive to the hospital I felt every acceleration in my uterus and back. I felt every tiny crack in the asphalt as well as the not so tiny ones. My body lurched forward when Neil applied the brakes and intensified my pain severely.

Neil apologized profusely and tried to find the balance between quick and cautious. I thought the fates were against me when we saw orange cones, excavators, and a construction crew providing after hours improvements on the road in front of the hospital.

We waited in the car for the pain to subside and then made a mad dash for the door. I quickly remembered that walking speeds up labor and intensifies contractions. The pain returned halfway across the parking lot. I stopped, wincing at the pain. We waited for my body to give me clearance to begin walking again.

Typically the labor and delivery nurse admits you to Triage, an observation room where they monitor your contractions, effacement, and dilation prior to officially admitting you. Luckily, Claudia called ahead and advised them to admit me upon arrival.

I vomited all over the hospital bed. The nurse gave me a hospital gown to change into and a little pink basin to capture any further projections. I vomited three more times. The basin wasn’t deep enough. In each of the three incidents the vomit ricocheted out of the bowl, all over my gown and back in my face.

As the labor and delivery nurse continually changed my gown she strapped on my external fetal monitors. The external fetal monitor is a monitoring device that uses two belts. One uses ultrasound to measure your baby’s heart rate and the other is a pressure transducer used to measure your contractions. The feedback is printed on a graphical machine to illustrate the baby response to your contractions. The elastic belts are strapped across your abdomen snugly. The extra pressure on my laboring abdomen was more than a subtle discomfort.

As soon as the monitor picked up the whoosh, whoosh, whoosh of my baby’s heart beat, the labor and delivery nurse began prepping me for the administration of an intravenous antibiotic treatment for my positive testing as a Group B Strep carrier.

Claudia arrived 10 minutes later. I don’t think I’ve ever been so happy to see anyone. It must have been the longest 10 minutes of my life. As soon as she entered the room she recognized my back pain for what it was: Back Labor! She quickly gave Neil a tutorial on how to apply Counter Pressure and relieve the pain. She performed a cervical exam and announced that I hadn’t dilated at all since earlier in the day, I was still measuring 2 centimeters! All that pain and no progress, are you serious?

She positioned me upright on the hospital bed with my knees raised and my feet flat. She pressed my knees toward me and downward forcing my tail bone against the back of the bed. I couldn’t believe the difference it made. The pressure was truly a natural anesthetic.
I looked at the clock 12:45a.m.

Our prenatal instructor taught that most first time moms average 12 hours in labor. If this was the beginning I couldn’t imagine how much worse it was going to get not to mention how much longer. The thought terrified me beyond all reason. Little did I know, I’d been laboring all day. I heard the woman in the labor and delivery room across the hall screaming, “Help! Dear, God it hurts, it hurts, it hurts!” The wails coming from her room echoed through the hallway.

I remember thinking if I’m only two centimeters into dilation how long will it take before I start screaming like that lady? “I want an epidural!” I announced.

The anesthesiologist arrived 20 minutes later. He instructed me to lie on my side curled into the fetal position forming an arc in my back. I thought I might cry. He was asking me to give up the counter pressure with the required position change.

I quickly complied. He washed my back with an antiseptic and provided a sterile drape. He then inserted a needle to numb the local site of the injection. He followed the local needle with a large needle intended for insertion between two vertebrae a little above the belly button.

He instructed me to hold perfectly still regardless of whether or not a contraction started. I lay still as the anesthesiologist slowly and carefully guided the needle toward the dural membrane and injected the anesthetic. He informed me that it would take 10-15 minutes before the numbing would take effect. The anesthesiologist then threaded a tiny catheter through the needle and taped it to my back.

Electing an epidural meant I must also receive a bladder catheter. Why hadn’t anybody ever mentioned this part of the procedure? I wasn't emotionally prepared for a physical invasion of my urethra.

Several minutes later I lay partially upright on my back. I could still feel every nerve in my lower body. But something wasn’t right. Breathing required so much effort. My fingers felt heavy and cold. My tongue was tingling. I couldn’t form words and I felt like my head was spinning. I silently thought I’m dying. I’m losing my ability to grip Neil’s hand. He’ll know I’m dead when I can’t hold it anymore. I wonder if I’ll hear the monitors beep in my last moments.
I concentrated with every fiber of my being, “Is the top of my body supposed to be numb?” I managed the question with a leaden tongue.

“What?” Both Claudia and the anesthesiologist expressed alarm.

Apparently the anesthesiologist accidentally inserted the needle with too much of an upward angle shifting the direction of the anesthetic flow upward rather than downward. They quickly flattened the bed and arched me back into the fetal position. The anesthesiologist removed the epidural catheter and began the process anew.

The anesthesiologist connected the syringe to a catheter and placed the syringe in a pump. The pump slowly depressed a plunger that provided a continuous dose of anesthetic. Fifteen minutes later I felt completely comfortable for the first time in several hours.

By this time it was 2:00a.m. I tried to sleep but it was difficult. My body shook convulsively. The shaking came so violently that my body tipped sideways. My husband propped me back up. My legs shook toward the edge of the bed. My vision was blurred. My blood pressure was 199/120. I appeared headed for eclampsia.

Claudia called for a Magnesium Sulfate IV Administration. This chemical stabilizes blood pressures and reduces the risk of cardiac arrest as well as minimizes the risk kidney or liver failure. I could feel the cool liquid trickling through the intravenous entrance of my hand. I fell asleep to this sensation.

Forty-five minutes later I awoke startled by a painful a new sensation. I thought my pubic bone was breaking. I pressed the call button for the nurse. Apparently the epidural numbs muscular nerves such as uterine contractions and cervical dilation, but the anesthesia cannot numb bone nerves. To make matters worse, I couldn’t move or adjust my position to alleviate the pain.

Claudia and the nurse returned.

“My epidural isn’t working.” I mistakenly thought the pain was attributed to an ineffective epidural. Claudia performed another cervical exam at which point she determined I was complete or a full 10 centimeters dilated. I also measured a +3 station which meant my body had been involuntarily working on fetal descent and the baby was beginning to crown. That’s when the pushing began.

My limp noodle legs continued to shake with random convulsions. Powerless and incapable of pulling my legs back into the classic birth position, I awaited assistance. Neil stood on one side and held back my left leg. The labor and delivery nurse, held back my right leg. Neil was stronger and better able to hold my left leg back in a true imitation of the classic squat, but the nurse seemed to master the angle with more comfortable placement. The lack of congruency annoyed me. I wanted to hold my legs back myself. I knew I could manage the symmetry better if I could evenly distribute resistance to both legs, but I didn’t have the arm strength and my legs were under temporary paralysis. They continued to shake, I felt frustrated with the lack of control I held over my body.

I delivered my baby sunny side up. This means she was facing up or occiput posterior. In this position the occiput or back of the baby’s head is toward the mother’s back. In a normal vaginal delivery the baby is born facing downward or occiput anterior. When the baby’s head applies pressure against the cervix with the crown in the anterior position it aids in opening the cervix.

Usually, there is not enough room for the baby’s head to pass through the pelvic chamber without rotating into the anterior position. This explains the extreme back labor pain as well as the feeling that my pubic bone was breaking. It was in essence being stretched to the max.
My birth plan expressed my desire to hold my new infant immediately after delivery and begin breastfeeding. What I didn’t anticipate was the presentation. I thought the nurse or C.N.M would provide a preliminary wipe down before handing me the infant. Not so.

Claudia instantly handed me my new infant dripping in fluids and showing a small amount of residue from the vernix caseosa or white filmy substance primarily comprised of sebum, fatty lipids, cholesterol and ceramide. Prior to birth I read that the function of the vernix is to moisturize the infant’s skin, provide a slippery passage through the birth canal, as well as offer antibacterial benefits.

Some women actually massaged the vernix or “baby cold cream” in to the newborn infant’s skin. On this my first pregnancy, I still felt a little squeamish. Neither my husband nor I were interested in reaping in this particular aspect of mother nature’s rewards. I sheepishly asked Claudia if she could wipe the baby down a little and place her in a blanket. Thus began our first swaddling.

Shortly after the swaddling began, Claudia noticed a contraction on the electronic fetal monitor and urged me to give a good push for the delivery of the placenta. The placenta exited the birth canal with little effort. The slippery and flexible amniotic sac molded much more comfortably through the already stretched vagina than a head and shoulders.

The labor and delivery nurse began rigorously massaging my abdomen in an attempt to expel any remaining placental tissue or blood clots. The aggressive massage initiated post delivery uterine contractions also known as after birth pains. These pains were hardly noticeable as the epidural still rendered full effect. I continued to swaddle and nurse my baby throughout the uterine massage.

Swaddling lasted for approximately 20 minutes while my baby’s umbilical cord slowly stopped pulsating. Our prenatal instruction explained that the cord pulsates much like a heartbeat as it transmits oxygen and nutrients from the placenta to the baby. I looked at the umbilical cord with wonder. The length didn’t surprise me. It measured approximately 20 inches or 50 centimeters long. It was the diameter or thickness of the cord that caught me by surprise. The thickness of the cord measured approximately ¾ of an inch thick or 2 centimeters. The cord initially appeared dark red with firm sinewy and fibrous walls in the places where it hadn’t calcified. As time passed and the cord slowly stopped pulsating, the color eventually faded. The volume of blood slowly filtered into my baby’s body providing her with her normal blood volume levels.

My reading suggested that early cord clamping, tying, or cutting can leave a baby low on red blood cells and act as a catalyst for an early onset of anemia. Other studies indicated that milking or allowing the cord to pulsate for longer periods of time allowed the cord to “milk” stem cells from the placental site. In class we discussed the option of saving your infant’s placenta and umbilical cord in a blood bank. The cord typically stops pulsating between 7 minutes for un-medicated births and 20 minutes for medicated births.

Claudia inspected the placenta to find that both the placenta and umbilical cord experienced extensive calcification. Calcification is a process by which the placenta begins to shut down. It appeared that the calcification had constricted the flow of nutrients to my baby. Claudia suspected that my baby had lost quite a bit of weight in the womb based on the excessive wrinkled skin.

I marveled at all of my baby’s fine, dark hair also known as lanugo. The hair covered the surface of her back, buttocks, and ears. The black hairs culminated at a point at the top of her ear reminding me of Spock from Star Trek. It appeared black while it was still wet with amniotic fluid, but later took on a dark brown appearance. Within a few weeks most of the lanugo fell out.
Following the delivery I felt ravenously hungry and hammered. I couldn’t tell what I wanted most: food or sleep. The only problem was that my husband was asleep in the chair and the R.N. kept forgetting to bring me food. Oh, what I would have done for some fresh fruit or a granola bar!

A couple of hours later the epidural catheter was removed from my back. The process felt somewhat uncomfortable, but not awful. I remained on a bladder catheter for the first 24 hours as they kept me on a Magnesium Sulfate IV for the next 48 hours and monitored my eclampsia. The Magnesium Sulfate most likely saved my life, but it left me feeling groggy and lethargic. It also limited my mobility. I couldn’t shower or use the bathroom. Even if I weren’t connected to a bladder catheter and a Magnesium Sulfate IV pump, I don’t know that I would have possessed the strength and energy to carry out the task anyway.

So what can we take from this experience?

- Labor is not predictable
- All contractions are not equal
- Ruptured membranes can manifest in the form of a trickle or a gush
- Cervical dilation is not an accurate indicator of labor progression
- Counter pressure is an effective natural anesthetic
- Epidural’s do not guarantee universal pain relief
- A laboring woman receiving an anesthetic epidural may not recognize the urge to push
- Most woman do not practice kegel contractions faithfully
- Healthy babies are derived from even the most unpredictable births
- You’re likely to exhibit the same behavior in labor that you exhibit in an argument (we’ll talk about this more in subsequent chapters)


Who is responsible for my dissatisfying birth experience? The anesthesiologist? My husband? Our childbirth educator? The hospital? Me? The Midwife?

The Anesthesiologist- The anesthesiologist did not ask me to get an epidural. He just happened to be the on-call doctor when the nurses woke him from a peaceful slumber and told him that the patient in L&D Room #11 wanted an epidural.

It is true that the anesthesiologist made a mistake in the first administration of the epidural anesthetic, but one incident was not the cause nor was it the worst consequence of my birth experience. We all make mistakes, even in our professional careers. We place high expectations on healthcare professionals to meet certain standards of performance, because we trust them with our very lives. Reason and mature emotional intelligence suggests we must accept that it is unrealistic to expect medical professionals to perform every procedure with perfect precision every time.

My husband- Neil was the only person who attended me from the first labor contraction to the last. He also had the least experience of all the other birth attendants. If he’d been a better labor support companion would the outcome have been different?
Expectant moms must remember they are not the only one entering unfamiliar territory. Their husbands are equally as frightened. Many men express their feelings of helplessness while their wife is in labor. One new father said, “I would have done anything to remove my wife from her misery. Even if it meant enduring the pain myself.” The problem is that there isn’t a magic transfer button.

The Child Birth Educator-. The childbirth educator spent a great deal of time emphasizing issues of consumerism or options at birth and terms and definitions related to the birth process. We dedicated many hours to learning how to stop medical staff doctors, nurses, and other hospital staff from botching up our birth experience.

She helped us choose a good provider and learn abdominal breathing techniques. We didn’t learn very many relaxation techniques, but we learned many birth positions to help alleviate pain. We learned much about the text book definitions of the anatomy, pregnancy, and birth, but we didn’t fully understand the role they would play in real life labor and delivery.
The hospital- The hospital did not solicit my patronism. I could have opted for a home birth or free standing birth center. The hospital room was clean and comfortable. The staff was courteous. My quarters were private. The hospital equipment detected and provided treatment for all of my risk factors. Although I must admit the bands of the electronic fetal monitors were terribly uncomfortable.

The Midwife- Claudia was wonderful. I wanted to send her flowers.

Me- I took the initiative to attend a birth class. I opened my mind to new options. I followed my caregivers instructions. I did all of my prenatal toning exercises on a regular basis. It couldn’t be my fault. The reality was that I botched up my own birth experience by not maintaining optimum health.

Many birth classes provide a good service in preparing and educating pregnant couples with techniques prior to the birth of their baby. If we want to look at the larger picture it is important to consider that the number one factor influencing the outcome of the baby is a healthy mother.

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