One of our pregnant citizens had a successful vaginal birth after Cesarean (VBAC) this weekend. Not to take a single credit away from her, but this is the kind of event which takes a village to achieve. Here's why:
A reader of this blog who was extremely helpful during my recent foray into high-tech library research has alerted me to a discussion about Birth Story #478 currently taking place in the comments of another blog. I have too much on my plate to respond to discussions taking place outside of this blog--heck, I can't even keep up with the comments here--so I will confine my remarks to the following:
I like to be on call on New Year's Eve and New Year's Day because part of me really hopes to be at the birth of the first baby of the year in Rural County. I know it's dumb, but I think it would be kind of groovy. Anyway, it didn't happen this year, but I had a remarkable New Year's birth story nonetheless.
All facets of medicine are difficult to teach, including childbirth care. I know some people will argue that childbirth is inherently different than all the pathology-based medicine we practice in the other areas of medicine, and I'm not going to argue the point, but learning about birth in all its complexity is very much like learning about, say, diabetes management in that you need to see a lot of cases and learn more than one approach to the topic in order to feel confident when the next patient walks into your exam room.
As I mentioned in an earlier post, I've kept pretty good records of all the births I've attended as a primary caregiver. I'm using the same Bellefontaine notebook as I started with and I believe I'm up to 476 or so births logged in that book. However, I've been around four times that many labors, newborns, and births as an assistant, and my perspective on birth comes as much from these experiences as the births that have occurred into my waiting hands. I'm going to be sharing some of those stories on this blog under the column title "Labor Files," and because a commentator recently asked if I have any VBAC experience I thought I'd start with my favorite VBAC story.
The widely-used practice of continuous fetal monitoring during labor has been criticized as a contributor towards the increase in operative deliveries via vacuum, forceps and Cesarean section. Available evidence suggests that continuous fetal monitoring does not improve neurologic outcomes in newborns, and even ACOG states either continuous or intermittent fetal monitoring are acceptable in low-risk pregnancies. Despite these recommendations, many busy Labor & Delivery units rely upon continuous fetal monitoring because they do not have the nursing staff to perform the check and rechecks necessary for adequate intermittent monitoring. In my practice, I prefer intermittent fetal monitoring because it permits the laboring woman greater freedom of movement and because it minimizes the chance I will see an isolated abnormality on the fetal monitor that might compel me to use unnecessary interventions.
However, sometimes I have to use continuous monitoring when a woman presents with a higher-risk condition of pregnancy such as gestational diabetes, or if her initial fetal monitor tracing (commonly called "the strip") is abnormal. I do everything I can to avoid interpreting the strip in a way which might lead the woman down the path to an operative delivery, even if it means I have to chew my nails to the quick until the baby is safely born. Here is one such tale.
I was covering Labor and Delivery one day during the second year of residency. We had the usual bustle of women arriving for labor checks, antenatal testing going on and had a few babies whose new cries punctuated the yadda-yadda of nurses, patients, and my own blithering.
Suddenly I heard my name being called to room 206. "Dr. Chan, we're having a baby in here!"
The last Birth Story I wrote described the worst shoulder dystocia I've encountered so far in my working life. It was a seven-minute delay between the birth of the baby's head and his shoulders, and it was the kind of seven-minute event which can change a person's life forever. I've heard of cases of shoulder dystocia in which the infant did not survive, or the mother suffered from significant injury, and I know of a number of doctors who have defended lawsuits after a bad dystocia. The outcomes are potentially bad enough that even when you have a good outcome, as I had, your gratitude may be diluted by fear. Some practitioners give up attending births after a near miss, even more change their practice style to become more conservative--becoming the kind of birth attendant they never wanted to be.
Whenever I've been involved in a scary incident, I remind myself of something I learned my intern year. I'd had a bad couple of nights on Night Float in which I'd attempted intrathecal analgesia twice on two different patients and not been able to get into the intrathecal space. Each time, my supervising third-year had to complete the procedure. So when the next night rolled around and my R3 approached me with a three year-old who needed a lumbar puncture, I hesitated.
"What's the matter?" My R3 asked.
"I've missed the last two spinal procedures I tried," I answered. "I think maybe it's better if you tap this kid, because--"
"Nope," the R3 interrupted. "You've got to get back up on that horse. You've got to do this one."
So we went up to the Pediatric unit, set up for the lumbar puncture, and--with my R3 standing behind me--I got in and did a champagne tap. Smooth and easy as if I'd been doing it all my life.
The moral of this story: If you're having a run of bad luck, keep trying. The worst possible outcome after a scary clinical scenario or a failed procedure is allowing uncertainty to take hold. Far better to try, try again than to hold back and never achieve any competence--or courage.
So, after the events in Birth Story #423, I decided to get back on the horse. Here's the story:
Nola was ten days overdue when one of the midwives I work with called me to say she needed to be induced. "I'm worried her baby's going to be really big," my friend the midwife said. "It feels huge."
Nola was a tall, sweet-tempered, strong-bodied yet heavyset young woman. Her pregnancy had been pretty uneventful but she'd gained about forty-five pounds since her first visit with us. Fortunately, a gestational diabetes screen was normal, and for that reason we'd waited until her due date had come and gone before considering induction. Now she was close to two weeks overdue and no signs of labor yet.
Some days on call are just a bit too rich for my blood. At first the pace is nothing, then--you wish you could vaporize from one room to another. Here's a recent call I took when I wished for wheels, not feet.
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.
In a previous birth story I wrote about the intimacy some couples experience when a woman is in labor. Even when there are other people coming and going, a woman and her partner can achieve a private emotional space. For other women, labor and birth are group events, with sisters, mother, friends providing essential support and respite for the partner. Occasionally a woman will take the group birth concept beyond a circle of intimates. Birgit had one such birth, as you'll see below.
If television is to be believed, the conclusion of labor occurs with an irresistible urge to push, followed by one or two extremely vocal expulsive efforts, followed by the lusty cry of a newborn. The truth, of course, is a bit different. Most labors begin gradually and crescendo when a woman experiences a strong desire to bear down. This desire may occur once her cervix is completely dilated, but it often does not happen for an hour or longer after dilation is complete. During this time, the fetal head descends and finally exerts a critical pressure on the lower vagina, causing an intense urge to bear down. At this point, most women--unless they have a dense epidural in place--cannot resist pushing and any attempts to get her to pant through her contractions "until the doctor gets here" are usually doomed to failure. However, every rule has its exceptions. I have known a few women who resisted the urge to push so strongly that I had to resort to drastic actions to get their babies delivered. This is the story of Dahlia, who didn't want to push.
Sometimes the third stage of labor is more memorable than the birth of the infant. In the middle of the night, it is so easy to let down your guard after the crying infant is placed in its mother's arms, but there is much more to to birth than that. I've had some placentas give me more grey hairs than the babies who preceded them. Here's one story.
One of the great pleasures of providing maternity care is being present at a woman's first birth. An even greater pleasure is being present at her second. Many birth attendants look forward to second and subsequent births because common wisdom has it that multips "go fast" in labor. Often times this is true. I like to tell women that their body is a trail that's been blazed; the second trek through the birth canal is easier than the first. However, I'm always very careful not to guarantee a quick second birth, because any one of a number of factors can affect the duration of subsequent labors:
A second fetus significantly larger than the first.
Malpositions such as occiput posterior ("sunny side up"), asynclitism (head tilted) or face presentation (face rather than crown first).
Psychological factors such as anxiety about experiencing the sensations of birth the second time.
I've had my share of rapid second, third, fourth, fifth, and even sixth deliveries. Once, after determining a woman was completely dilated, I told her--casually--that she could push with her next contraction. She did, and the baby crowned before I could get fresh gloves on, so I had to deliver him with my hand covered with a bedsheet. On the other hand, I've also had more than my fair share of long second labors. Here's one such story.
A 24 year-old primigravida showed up at our Labor and Delivery one fine afternoon. I was called to evaluate her because she had her prenatal care with one of the OB-GYNs who does not deliver babies at our hospital. She'd been triaged at the other hospital where her doctor has privileges but discovered she didn't like the place, and decided to give our hospital a try.
She was a very pretty young woman, funny and bright during her early labor. "I'm going to do this natural," she announced to me. "I know I can do it."
Why not? I thought to myself. She seemed to be a healthy person, although not of a particularly athletic build, rather one of those quite thin young people who manage to stay slender even though they exist on a diet of potato chips, energy drinks and cigarettes.
While hanging out with Dr. Anonymous at Ustream a couple of weeks ago, I was chatting with Mexico Medical Student and Medi-Medi-Mary about waterbirth. I don't know the exact origins of this childbirth practice, but it is very popular up here in Rural, CA. In many communities it is available only for homebirths, but my hospital's maternity unit permits waterbirths for select women. Criteria for waterbirth include documented negative serologies for Hep C and HepBcAg. If HSV-2 serology is positive, a woman must take acyclovir in prophylactic doses beginning at 36 weeks. Of course, the woman's pregnancy and labor must be low-risk to permit waterbirth.
Despite these hurdles, a lot of women in our practice elect to try a waterbirth. Most of them do not end up giving birth in the Aqua Doula tub, which they rent from a local woman who is a homebirth and waterbirth advocate. Some woman find the tub too hot at the required 99-100 degree temperature. Some women find they dislike being in the water as their labor progresses. Of course, if labor is not straightforward, a number of medical interventions might require a woman to get out of the tub for closer monitoring.
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'm reading a great book entitled The Girls Who Went Away, by Ann Fessler. It's social history of birth mothers in the United States during the post-WWII years until Roe v. Wade was passed in 1973. During that time, unmarried women were frequently sent to maternity homes to await the birth of their child, then were pressured to surrender the baby for adoption. These young women rarely received adequate counseling about pregnancy, childbirth, social services, or alternatives to adoption. Fessler recounts the pressures they faced from social workers, peers, and their own families to surrender their own children, and the emotional devastation that followed this event. It's a gripping read and I highly recommend it. If you have a Kindle, the book is available in electronic format as well.
Reading The Girls Who Went Away got me thinking about a young woman whose birth I attended a couple of years ago. Let's say her name was Caroline.
I keep a book with the names of all the women whose births I've attended. It starts with the first baby boy I delivered as a fourth year medical student, and ends with the little boy I delivered last Friday. During my third year of residency, I mislaid the book for several months, so I missed at least 40 births during that year. I gave myself a low estimate of 293 births by the time I graduated; the actual number was probably higher.
While bringing the book up to date last weekend, I was amazed to discover that I have delivered 461 babies during my short time as a family doctor. That includes two sets of twins and a whole bunch of second babies for women whom I'd attended for their first birth. It does not include C-sections, which I never count. Along with date of the birth and the woman's name, I make notations about the circumstances of the birth: "I arrived to see someone else. She was on her hands and knees at the nurse's station, wailing."
Four hundred sixty-one births. That's almost 500, a number I associated with wise women and elders in a community. Me? Maybe I was wrong.
From time to time, I'll write about a memorable birth story. Glad I kept track all these years.