I've been writing up several home birth transfer scenarios in the Birth Stories recently. This is in preparation for a post series on home births in Rural, CA. and also because I have been entering into some interesting dialogues with other alternative birth proponents. I never had any experience working with home birth clients before moving to Rural, so the last few years have been a crash course for me. I have had a number of wild and goofy experiences working with home birth clients who decided to transfer to the hospital, and a number of stranger situations that really made me wonder about the psychological dynamics of birth. Barbara had one such birth.
Barbara was a first-time mother, a really beautiful young woman, fit and healthy. Like Dahlia, she always came to clinic looking incredibly well put-together--hair artfully wild, face made up, lovely artistic clothing. Meeting women like her make me nostalgic for my early adulthood, when I was fresh-faced and effortlessly lovely. That phase of my life lasted about 20 minutes. Barbara made me remember those 20 minutes fondly.
Barbara was working with Kathleen and her midwife partners, hoping for a home birth. One of Kathleen's partners, Celia, confided that she wasn't sure Barbara was an ideal candidate for a home birth. Kathleen wasn't worried, but Celia questioned Barbara's motivation at times. "She keeps talking about an ideal birth and isn't making concrete plans to get her house ready or whether she wants her mother to be there. She talks about other women who have had a home birth as if they're professional athletes or something. I just worry that she thinks there some kind of merit badge in having home birth, or that she's got something to prove."
Celia's a pretty shrewd judge of character, and I meditated upon her concerns about Barbara's suitability for home birth. The midwives who attend home births in Rural interview their prospective clients carefully. They are looking for healthy young women who can adhere to a rigorous program of self-care (healthy diet, regular exercise, yoga, standard prenatal visits at our clinic) and who are prepared to take responsibility for the outcome of their birth. This last quality is nebulous but critically important. By opting to give birth at home, a woman must prepare herself for the possibility of neonatal and maternal injury, illness or death--and the possibility that these outcomes might have been avoided by a hospital birth. Kathleen discusses this commitment pretty frankly with her clients, and her services as a doula for a hospital birth are always offered as an alternative. The discussion is not limited to their first meeting but is renewed regularly during the course of a woman's pregnancy. It is a model example of informed consent as an ongoing dialogue rather than an isolated discussion.
Celia's concerns went to the heart of the choice of home birth over hospital birth. Although there are many reasons for a woman to want to give birth at home--comfort, autonomy, desire to avoid medical interventions--most of the home birth midwives would not encourage a woman to give birth at home solely to join the elite network of women who did so. Yet there are some women who pursue the option for just that reason. This is not to disparage the home birth movement, because I don't believe that is what it is about, but somewhere along the line there has developed a subculture of women who are determined to give birth at home because it is the cool thing to do, rather than the right thing to do.
In my interactions with Barbara, I came to agree with Celia's concerns. Barbara always listened to what I had to say, and when I gently inquired about childbirth education and any preparations she was making for going through labor, all she said was "Oh, Kathleen and Celia are teaching me all about it." Her speech was airy and unconcerned, and this troubled me. Most women who have contemplated giving birth have a healthy respect for the process, and I like to see an openness to the unknown develop over the course of pregnancy, because none of us know how a labor will progress.
Why are these important issues? Because a woman's psychological preparedness for giving birth really matters. Women have to reach deeply into their inner selves during labor, and they need to have some self-reflection to get to those deep places. It was possible that Barbara had reflected upon her inner self and was putting up a strong public show, but I sensed a true avoidance of the issues from her, and this is what was worrying.
Despite these doubts, Celia was with Barbara on the evening she went into labor. The early part of labor was uneventful. I heard nothing about it all day, when I was rounding on a difficult hospitalist service. Finally, late in the evening, after seeing 20 patients, I was staggering home. One block away from my house, I received a page from Labor and Delivery.
"Celia's sending a home birth patient in by ambulance," Roberta, one of the nurses, informed me. "It's Barbara, you know her? Well, apparently she had a seizure at home. House supe wants to know if she should call in the OR crew for a C-section."
I was pretty tired and a teeny bit grouchy. "Why would we need A C-section?" I asked. "I mean, even if she's eclamptic--" I started to turn the car around and head back to the hospital.
Preeclampsia describes a medical complication of pregnancy that usually develops in the third trimester and is characterized by high blood pressure; measurable protein in a patient's urine; and swelling of the hands, face and feet. Preeclampsia may also be diagnosed on the basis of other blood tests and findings, but the classic diagnosis is made on the basis of the three findings mentioned. Eclampsia describes a complication of preeclampsia, namely the progression to an eclamptic seizure. These are usually tonic-clonic or "grand mal" in type, although I have heard of focal eclamptic seizures as well. Of course, other diseases may cause seizures in pregnant women, including epilepsy, but these are usually identified before the onset of labor. Seizure occurring after the onset of labor is highly suspicious for preeclampsia.
By the time I arrived back at the hospital--again--Barbara had been transferred from ambulance gurney to hospital bed. Labor and Delivery was in full crisis mode, with the House Supervising Nurse standing by and staff nurses running all over the place. Barbara's mother, Nan, and her husband, Doug, were also there, as was Celia. Kathleen had stayed at home with Doug's older child from a previous relationship. When I entered the room, Barbara was lying drowsily on her side. Roberta was starting an IV, and Holly--another nurse--was strapping on fetal and contraction monitors. Phones were ringing and all the lights were on and there was a general sense of being on the verge of chaos in the room.
I was looking at Barbara. I ignored everyone else, including Nan who was wringing her hands and Celia, who was trying to bring me up to date. I wasn't trying to be rude, but one thing I have learned in my short career is to focus on the patient. Especially when there is an emergency. What I saw was a woman who did not show any evidence of seizure at the moment, whose blood pressure was only 136/88, who was contracting every 4 to 5 minutes, who panted and moaned through the contractions, and whose fetal monitor showed a normal heart rate although only moderate variability. In other words, things were fine at this moment. No need for a C-section at this time.
I explained this to Celia, Nan and Doug. An eclamptic seizure is not an absolute indication for delivery by C-section. In fact, the anesthesia risk is greater in a woman with preeclampsia, so the decision to do a C-section should be made for good reasons. I could tell Nan didn't like this answer, and Doug looked uncertain.
Barbara's IV was in and I started a large bolus of magnesium sulfate, which is the standard treatment for preeclampsia. The standard labs had been drawn and were completely normal--no protein in the urine, no abnormalities that went along with the other types of preeclampsia. Furthermore, Barbara's blood pressure hadn't been higher than 138/88 since arrival, and she had no signs of any edema in the face/hands/legs.
Was it possible that Barbara didn't have preeclampsia? I couldn't really get a sense of what was going on from her, because she was really drowsy now that the magnesium was running continuously. The baby's heart tracing looked fine, and Roberta reported a cervical dilation of six centimeters. I knew we had some time to figure out what was going on, because mother and baby were OK. So I reviewed the events that had occurred at home with Celia and Doug. Nan preferred to hover over her daughter, and I think she was mad at me for not endorsing the C-section idea.
Apparently, Barbara had a long early labor but coped well by alternating short walks with showers and warm tub soaks. Her waters had broken spontaneously and then labor picked up pace. Celia knew things were getting very intense by the volume of Barbara's vocalizations. "She was yelling and thrashing around with contractions. I was trying to get her to focus, get her to squat or do something in rhythm with the contractions, but in between she panted and wouldn't listen to me," Celia explained. "Then, suddenly, she closed her eyes and flopped back in bed and it was if she couldn't hear any of us. Then she started shaking all over."
Doug agreed with this description. I tried to get them to be more specific about the movements Barbara had demonstrated. Were they flexion/extention movements? Or tremor? "It's like she got tight and she just shook all over," Doug said.
"I'm not sure if she bent and extended her arms and legs," Celia said. "I'm sorry, I'm really not sure." The strangest thing, she and Doug agreed, the most worrisome thing was that Barbara had just stopped talking to all of them. They called her name and patted her hands and even shouted but she kept her eyes closed and wouldn't answer.
I was in the middle of a diagnostic dilemma. On the one hand, I doubted the diagnosis of preeclampsia/eclampsia. The seizure episode didn't sound right, the blood pressures and labs were all normal, and there were no other symptoms. On the other hand, it is possible for a woman to have an eclamptic seizure without the other findings, although this is unusual. The event Celia and Doug described really didn't sound like seizure. It sounded more like a dissociative episode--a retreat from consciousness, perhaps precipitated by acute physical and psychosocial stress--or even a pseudoseizure. But I hadn't been there to witness it.
This is one of the most frightening prospects of home birth: the development of a grave complication away from the presence of experienced witnesses. Try as they might, Doug and Celia couldn't really put together an accurate description of the physical event Barbara had gone through. They were focused on her inattentiveness, they were worried about her--but they hadn't really looked at what was happening to her. I don't blame them at all. But it put me in a tight spot.
I decided I had no choice but to proceed on the assumption that Barbara had experienced an eclamptic seizure. The clinical picture wasn't right but there was enough concern that it made sense to continue magnesium and actively promote labor. Delivery of the infant is the ultimate cure for the disease.
By this time, Barbara's cervical exam was 8 centimeters. She was still drowsy and inattentive, but if I brought my face close to hers and insisted she open her eyes, she understood me well enough. I explained the possibility of preeclampsia, the need for magnesium, and now the need for a bit of Pitocin because her contractions were spacing out. Even though she was dilating steadily, I didn't want her labor to lose any pace. Magnesium would hopefully prevent another seizure, but preeclampsia never gets better, and doesn't go away until the baby is born.
This is my obstetrical side. I like to think of myself as extremely liberal and open in my approach to normal labor and birth, but if things become abnormal, I am a doctor and my job is to intervene. Whatever had happened at home, Barbara's labor had veered far from the normal curve, and I was going to manage her labor aggressively.
Roberta started Pitocin. Within an hour, Barbara's cervix was fully dilated. Her initial pushing efforts were perfunctory. In retrospect, I may have got her pushing too early. Women on magnesium feel heavy and drowsy, and it might have been better to wait until the Pitocin had labored the baby's head down, but Barbara thrashed and moaned with each contraction and I thought it would help her to push with the discomfort, to have something to do with it, rather than have to put up with the sensation. The "take charge" approach did nothing for Barbara. When we encouraged her to push, she grunted briefly then resumed moaning and thrashing. She listened to no one--not me, not Celia, not Doug, and certainly not her mom--but she was definitely not seizing.
Thankfully, night shift came on and Roberta was replaced by Vicky. Shift change can feel disruptive at times, but other times a new face with new energy is revitalizing. Vicky is a no-nonsense, can-do kind of person. She entered the room, introduced herself to everyone, and observed Barbara for a while. After a while, I felt her moving forward, into the dysfunctional energy surrounding the labor bed. Vicky took Barbara's face between her hands and said: "Listen to me. No, listen to me. You're going to stop carrying on now, and you are going to start pushing. I'm going to help you."
Vicky rearranged the room, repositioning Barbara in bed, seating Nan in a chair so she wasn't hovering too close, and stationing Doug and Celia on either side of Barbara for support. I became one of her minions too, and quite happily so. Vicky told me to give posterior pressure and she counted each push out to ten. The energy in the room was brisk and positive, instead of fearful and uncertain as it had been for many hours. At first Barbara fought all these efforts, but soon she was hypnotized by Vicky's energy, and she pushed.
Young Liam Alexander was born about an hour later. Barbara's blood pressures and Liam's heart tones were fine throughout the second stage. There was a minor laceration, but otherwise the birth was uneventful. Doug bonded with his new son right away, but Barbara was unwilling to hold him at first. I took note of this but didn't worry too much--some women don't have that overwhelming joy you're "supposed" to have at first sight of your baby, and magnesium will sap the pleasure out of almost anything. After a few hours of rest, however, she met her son with delight.
To this day, I have no idea exactly what happened with Barbara. In the medical record, I said she'd had an eclamptic seizure, gotten appropriate interventions, had a spontaneous vaginal delivery, and an unremarkable postpartum recovery. I believe the truth is much more complex than that. I just wish I had been there when she'd first closed her eyes, and refused to answer to her name.