Some birth stories capture the spirit at different levels. The birth of Maura and Luke's baby might affect you differently than it did me, but I'm sure it will touch you.
I've heard of high school sweethearts but met very few of them. Maura and Luke stood out among our prenatal panel because they had been together since sophomore year, the year Luke was diagnosed with Hodgkin's lymphoma. Maura talked to Luke on the phone every night when he went to the far-away tertiary care center for chemo/radiation therapy. Maybe that's why they turned out to be such an enduring couple, joined by the bond of illness, uncertainty, and then the joy of cure. After treatment, Luke was pronounced free of cancer, although as a result of his treatment, he would never father a child of his own.
As they grew up they made plans for a child-free life together. They pursued advanced degrees and international travel, and lived in a number of urban settings before returning to their home base in Rural. "There aren't enough trees in a city," Luke told me. He was a slender, sensitive-looking man, with piercing blue eyes. Trees and all growing things were important to him, he was a plant biologist. Maura, a writer, could do her work anywhere and was, she said, perfectly happy being part of a married couple without children. She was involved with charitable organizations and political advocacy and led a full life.
And then she discovered she was pregnant.
During the amazement that followed, Maura and Luke examined the assumptions they'd made about their life. They'd never considered being parents. Did they want everything to change now? What about travel, scholarship, activism? And, in their mid-30s, was it too late to change their concept of themselves?
Apparently not. By the time I met them, Maura was well into her second trimester and was intensely happy about the possibilities of her new future. She had set aside her big writing projects and was focusing her efforts on having a healthy pregnancy. She swam, attended prenatal yoga, ate carefully, and treasured every moment of this most unexpected pregnancy.
Maura turned to Kathleen for a home birth midwife. Kathleen asked me if Luke's history of cancer treatment was likely to affect the fetus in any way. "I doubt it," I said. "If anything, that one surviving sperm must be a supernova of good genetics." All of Maura's prenatal testing was reassuring, so I had no particular worries about her pregnancy. She fell into the category of low-risk women for whom home birth is a reasonable option.
Not only was Maura low-risk on paper, she felt low-risk to me. I never worried about her or her home birth decision. This is not always the case for me. Some women, such as Barbara, choose home birth and I worry about them until the moment they walk into clinic holding a healthy newborn in their arms. Fortunately, there are many women who have safe, happy births at home in our community. But there have been a number of complications among other home birth mothers, some minor, some fatal, and I worry the next home birth will bring on some terrible new statistic. However, every so often there is a woman whose approach to home birth is so serene and open that I do not worry at all. Each one is a gift to me.
I was so unworried about Maura that I was surprised to receive a call from Kathleen one night I was on call. "I've been laboring with Maura," she said. "Her waters broke yesterday morning and labor got started early this morning. I haven't checked her very often but last time I did she was five centimeters. She's contracting every 1-2 minutes and getting tired. I also think she's worried about being ruptured so long."
"What was her GBS?" I asked. Group B streptococcus is a bacteria that normally colonizes the female genital tract but can cause a devastating infection in a newborn. Current guidelines recommend testing women for GBS when they are 35-36 weeks. Those who are heavily colonized are recommended IV antibiotics during labor. Home birth clients often forgo GBS screening, because we can address timing of antibiotics using other risk factors, but Kathleen likes her clients to be screened so she can limit the number of hours of ruptured membranes a woman labors at home before recommending transfer to the hospital.
"And what's her temp?" If GBS is negative, the next thing to follow is a woman's temperature curve. Development of fever is a sign of chorioamnionitis, or infection of the amniotic fluid and membranes, and requires evaluation.
"She's afebrile," Kathleen answered, and mentioned another reassuring statistic: the fetal heart rate was normal and showed no sign of stress during contractions,
"Well, she can stay at home if she wants to," I said. "I mean, thirty hours of rupture is a bit long, but I can live with it if there's no fever--"
"I think--" Kathleen began, and I could almost hear her thinking. "I think Maura would like to go to the hospital. I can't really explain it, but I can sense her anxiety about the prolonged rupture and I think it's affecting her labor. I can see it on her face. Maybe if she went to the hospital, she could let the worry go."
"Why don't you talk it over with her and see what she wants to do?" I suggested. "I can go either way, so there's no pressure. She can labor at home for a while longer, or she can come to the hospital, or you can call me again and we'll talk it through again.
This is how Kathleen and I work together. She is a childbirth educator at our clinic, teaches childbirth classes at the hospital, and provides home birth support as well. She's been attending home births in Rural County for decades, and although she doesn't know a lot about the medical aspects of labor and delivery, she knows a lot about everything else. I trust her judgement, and she knows she can call me up about her home birth clients and I'm not going to freak out and insist everyone transfer to the hospital. We don't agree about everything, of course, but we agree about a lot of things. All of the doctors and midwives at our clinic have a similar working relationship with Kathleen. It's a great example of parallel care between medical providers and home birth midwives. I'm not saying it's perfect, but it is pretty good.
Later that afternoon, Holly called from Labor & Delivery. "Maura's here with Luke and Kathleen," she told me. Maura's temperature was normal and the baby's heart tones were reassuring. Amniotic fluid was still leaking but was nice and clear.
"What does she want to do?" I asked.
"She wants to stay," said Holly. "She's tired out from contracting since yesterday."
"Does she want anything for pain?"
"Maybe, but first she's going to get in the tub."
After a good long soak, Maura felt a bit more energetic. The contractions were still coming regularly, and they were more intense, but now they felt athletic in strength, rather than energy-sapping. Holly called me back. "She's eight centimeters, you'd better come on in."
I obeyed. On my way to the hospital I pondered the reasons for transferring from a home birth to a hospital birth. Sometimes women tire out from a long labor and want something to relieve pain. Other times, their midwives sense that labor is not going well and recommend transfer. Still other times, the home environment isn't as comfortable as expected, and the hospital provides an unexpectedly attractive place to go. Maura didn't quite fit into any of these reasons. Maybe Kathleen had it right, and she just wanted to stop worrying.
By the time I arrived, Maura was in transitional labor. I could tell by the eyes-closed, otherworldly posture she adopted as she leaned against a squat bar. During contractions she breathed deeply and her body trembled slightly. This often occurs during transitional labor.
I inserted myself into the birth room discreetly. The lights were low and it was quiet. I try very hard not to be one of those doctors who flings doors open, flips on lights and starts talking in a loud voice. I waved at Luke and Kathleen, then knelt on the floor in front of Maura.
I asked how she was doing. She opened her eyes slightly and smiled at me. "Okay," she said, and went back into her deep place.
"She's glad you were on call," whispered Kathleen.
"So am I," I whispered back.
We waited in the quiet, dim room as Maura's vocalizations evolved from simple breathing, to mid-pitched humming, to deep-pitched guttural explosions. She was pushing. Without any coaching, she fell into a pushing pattern that was vocal, but sustained. Kathleen guided her pushing, encouraging her to relax completely between contractions, reminding her to let her shoulders drop and to take sips of ice water in preparation for the next exertion.
When a home birth client decides to transfer to the hospital, I make an effort not to impose my presence on the birth as long as everything is going well. I figure the woman wanted to give birth at home for a more private, intimate experience, and even if she transfers to the hospital for comfort, reassurance, or pain medication, that doesn't mean I have to go in with latex gloves on and interrupt the rhythm or pace of her birth experience. Of course, if there is something worrying going on--fever, rising blood pressure, maladaptive labor pattern--then I'll switch modes and suggest interventions, but everything is going well, I can be a fly on the wall and let events unfold as they may. Especially if Kathleen is there to support her client. Kathleen is the best coach I know.
Maura's pushing became more and more muscular and determined. Her vulva began to bulge and I signaled to Holly to prepare a delivery table. Maura was pushing well in a forward seated-squat, which is often a great position for pushing, and also allows the attendants to watch the descent of the fetal head.
I'm always amazed at the rapid acceleration at the end of the second stage. For an hour, nothing visible happens, then suddenly--a bit of head begins to appear at the woman's introitus. The flash of scalp appears, disappears, reappears, and grows bigger and bigger. Pretty soon it stays visible between contractions, and the next thing you know, the head is crowning.
Maura's baby was born with my hands only serving to guide her little, wet body down onto the bed, then back up to her mother's waiting arms. "Oh, it's a girl," Maura said, almost as if she were speaking to herself.
"Was this a surprise?" I asked.
Luke smiled. His eyes were like blue lanterns in the dark room. "Yes," he said. "We didn't want to know beforehand."
They named the baby Lilya, after Maura's grandmother. Later, as the new mother took a well-earned nap, Luke rocked his daughter and told me of the baby shower held for him and Maura months earlier, at the home of his sister who lived near the cancer center where he'd received treatment. "I didn't know what they were thinking, asking us to go all the way over there for the shower," he told me. "My sister said it was because her house is big and laid out for a crowd. Anyway, Maura and I drove down, and thing thing was--my sis invited the doctor who took care of me during my chemo, and some of the nurses and aides too. They'd found out about the baby, and they wanted to see us. We're a success story for them--well, I mean, Lilya is the success, you know? No one ever thought she'd be here."
Lilya wasn't born at home, but her birth was perfect, and her life was a most welcome surprise--a gift to her parents, to the medical staff who'd cared for Luke, and to me, who got to be there when she first opened her eyes and saw the new life she'd created.