Birth Story #345: A Beautiful Second Birth

I fall into a bad habit most doctors are prone to:  I over-recall abnormal and dramatic events, and under-recall the normal and the commonplace.  When I sit down to write a Birth Story, I find myself gravitating toward crisis moments, near-misses, and heart-in-your-mouth moments.  Yet, when I'm on call, I long for the beautiful, uncomplicated birth that involves me only as a witness, not as a technician.  This is the story of one such birth.

I met Pilar for the first time the day before she gave birth.  She'd been seeing one of the other doctors in our practice most of the time, as scheduling conflicts had kept us from having an appointment together.  In the exam room, she told me she'd been having some crampy contractions, not intense but noticeable.  The pains were sporadic and not terribly bothersome.  I examined her and found she was 2-3 centimeters dilated.  We discussed the options for admitting her to the hospital immediately or waiting until her labor got rolling in earnest.  She chose to wait and she and her husband went for a walk on the beach.

I wasn't surprised when our Labor and Delivery unit paged me several hours later.  Pilar was there, contracting every four minutes and coping well.  I joined her there and examined her again--she was 5 centimeters dilated, almost fully effaced, and her waters were intact.

Pilar's husband, Eliot, was providing excellent support.  He rubbed her back and her shoulders as she leaned against him.  Eliot had the kind of peaceful, confident demeanor that immediately centers a birth room. Watching them move in sync from standing to squatting to kneeling positions reminded me of a successful dance couple in performance.

Pilar wasn't in much of a talking mood.  Every so often, Eliot murmured in her ear and she murmured back to him.  We were monitoring the baby intermittently, and the heart tones looked very reassuring so I felt fine leaving them off most of the time.

The majority of women like having me check in with them while they are in labor, and some really want me to stay in the labor room with them as much as possible.  Pilar was different.  Her connection to Eliot was palpable; although neither of them seemed to mind my presence, neither was particularly focused on me either.

I realized my presence in the labor room was superfluous, so I exited discretely and awaited developments outside the room.  Pilar's nurse, Anabel, was also waiting outside.  We talked about the intimate quality of Pilar and Eliot's partnership, and agreed they were doing well without us.  Every so often, Anabel slipped into the room to check the baby's heart tones and Pilar's vital signs, but for the most part both she and I stayed out of the room to allow the couple to labor together.

Pilar's waters broke about two hours after she'd arrived at Labor in Delivery.  Immediately, the intensity of her labor increased.  She started making "deep sounds"--gutteral moans and long, sustained keening sounds, and then--a series of grunts.  Anabel and I looked at each other.

"I think maybe we should get in there," I said.

Just in time.  Pilar was pushing instinctively.  A quick exam confirmed she was completely dilated and the baby's head was within a half an inch of crowning.  She was squatting in bed, and Eliot was kneeling on the ground beside her.  The connection between them was unbroken.  Eliot was murmuring words of encouragement to her, and whatever he said worked well.  There was no need for any energetic counting or cheering on to promote her pushing efforts.

Four, five, six sets of pushes later, the baby's head crowned.  "Here we go," I said to her.  "You're almost there."  The next push brought the baby's head.  Pilar, probably sensing the end of her labor, gave a mighty push and the baby's body was delivered.  I passed the baby--a girl!--up to Pilar's chest, so Anabel could dry and suction the new arrival.

For some couples, the process of labor and birth is an intimate event. requiring no attendants other than the to-be parents.  For those couples, I am happy to stand outside the intimate circle until I am needed.

Comments

[Theresa]

This is why I think FPs have a different perspective on childbirth practices: they take care of babies as well as mothers. I took care of one newborn with a fetal-scalp electrode abscess once, and that changed my attitude towards unthinking use of internal monitors forever. If I have a good reason to use them, I do. If I don't--I remember that abscess and refrain.

[Hilary]

Whoops! Residence = residents. Sorry for the typo!

[Hilary]

Being a frequent reader of AHRQ, I was well aware that continuous fetal monitoring is not linked to improved maternal or fetal outcomes, just to increased cesarean rates. I am in an area (South Florida) in which hospitals tend towards increased medicalization regardless of the evidence behind the practice. In fact, a new attending at the only ob/gyn residency in the area told me she was shocked to find that the residence were trained to use INTERNAL fetal monitoring on all laboring mothers.

It is refreshing to know that in other areas that intermittent monitoring is considered acceptable protocol in a hospital setting.

[Theresa]

There is not evidence that continuous fetal monitoring improves outcomes, but I associate its almost universal use with limits of staffing. At a busy hospital, a nurse may not have time to apply and remove monitors every 15 minutes during the second stage, or whatever local guidelines demand.

In Rural, most of the nurses are supportive of a low-intervention birth, and the pre-printed order sheet allows me to check off "intermittent" or "continuous" for fetal monitoring. So many of our nurses are willing to hold a monitor on for a few minutes then remove it so it doesn't bother a laboring woman. So it really, really depends on the philosophy at the hospital.

[Hilary]

What a beautiful birth story! I trained as a midwife in a freestanding birth center before attending medical school. I have been a doula at several hospital births in the area. I love your birth stories.

I have only seen intermittent monitoring at out of hospital births. How many hospitals would allow or encourage intermittent monitoring instead of continuous monitoring? I was surprised but happy to see you mention it in your birth story. I mentioned the difference today when giving a tour of the birth center to fellow medical students in our Ob/Gyn interest club.