Big Blessing!

I was recently asked if I had read my blog lately, and I had to admit I had not.  Come to think of it, I think I have let life get in the way...What, no new stories for over 4 years?!  What can I say?  A lot has happened in 4 years.  My Nurse-Midwifery enjoyment of being a part of so many wonderful women's lives and that of their families is now in now in year 21.  What a wonderful ride it has been. Busy office days, on call, somewhat unpredictable, but always enjoyable and doable, and I seem to thrive on it.  But back to a new story, or by now I probably have several I could share.

A seasoned mom in her third trimester of pregnancy was beginning to measure large for dates at her visits and an ultrasound was ordered to get an estimate of how big the fetus might be.  Yes, It predicted a baby greater than 90% estimated fetal weight, and although the ultrasound in third trimester can be off by one pound or more either way, a decision was  made, after discussing risks and benefits, for a planned induction of labor at 39 weeks.  Multiparous mothers (greater than one prior pregnancy) are pretty easy to induce or start labor in, for the muscles have done that labor dance before, and sometimes all it takes to get things going is a little Pitocin through an IV or AROM (artificial rupture of membranes) and the body soon remembers just what it needs to do.  So we had a plan.

Two days before planned induction, the mother to be called the answering service with regular contractions. Since this was her 7th term pregnancy she was advised to head to the hospital to be checked out.  Sometimes mother nature kicks in and God blesses women with labor prior to a planned induction when that's just what they need.  On admission she was 6-7cm dilated, still had time for IV fluids and antibiotics for group B strep x2 and a few hours later was delivered by my on call partner, Meg of a healthy viable ...drumroll...11# 3oz... baby girl!  Wow!  One of the benefits of a natural, unmedicated labor and birth is that the mother can feel the urge to push and assist her body with the delivery.   Great job, ladies, and welcome to the world baby Grace.  Can't wait to see what God's plan is for your sweet life.

Showers of Blessing...

We all love surprises!  Since mom and dad already had a son and a daughter at home, they chose not to learn the gender of this baby at the 20 week anatomy survey ultrasound.  This baby would be a tie breaker, and a surprise to look forward to.  In this time of advanced technology, there are few surprises.
 
The pregnancy went along very low risk and uneventfully without health concerns outside of mom's age being over 35.  A woman's preparedness for labor begins in her mind, her expectations, and in her ability to trust her body to give birth.  As the due date was approaching we discussed mom's desire for an un-medicated, natural labor and birth, delayed cord clamping to allow oxygen rich blood to go to the baby, and for mom to hold her baby right away if all went well.  Since mom was dilated to 3 centimeters at 38 weeks and 3-4 centimeters at 39 weeks, we felt she would go into labor on her own prior to 40 weeks.  Only 3% of babies are born on their due date, with the majority of the others falling around 10 days before or 10 days after, and a few outliers in the very preterm or postdates.  At 39 weeks I swept her membranes for her, which is often followed by spontaneous labor, and again at 40 weeks...to no avail.
If mom had been under 35 years old we would have given another week for her labor to start, but feeling it was in her and the fetus's best interest to be delivered, a plan was made to put her in the hospital at 40weeks, 3 days.  It would be a low intervention labor of a 20 minute non-stress fetal monitor tracing, followed by AROM, or artificial rupture of membranes and ambulation to get labor started. 

The appointed morning came and mom and dad wondered why God hadn't answered their prayer for labor to start naturally at home.  A reactive non-stress test predicted a healthy fetus with good placental reserve for the work of labor.  Mom's water was released with an amnihook, and small leakage promised more water to come.  Even when the water is released before the baby's head the body continues to form more water in the amniotic sac to cushion the baby.  As I left the hospital to go to the office and see patients during the morning only, mom and dad were briskly walking the halls, smiling and chatting the time away.  As she was 4 centimeters and 70% thin when I broke her water I'd give her until noon to change.  I planned to return to the hospital around noon or whenever the nurse called to tell me she was frowning and working harder.
Mom spent the morning walking, sitting on the birthing ball, drinking water, eating pop sickles, and walking some more.  Intermittent electronic fetal monitoring reassured us that the little surprise was handling the demands of labor just fine, thank you. 
Calling the hospital at 11:50 to ask how my patient was doing, I was told she was sitting on the birthing ball and her contractions were every 3-4 minutes.  She seemed to be coping well.  Good, I thought.  Maybe she won't need Pitocin to pick her labor up. The nurse practitioner student and I headed in to see our last patient for the morning.  At 12:15 I grabbed my keys and lunch and headed down the 4 flights  of stairs to my car and back to the hospital.  Half way to the hospital my phone rang, "Donna, she's 7 1/2 centimeters now and in the shower and uncomfortable."  "I just crossed the bridge, I'm on my way," I replied.
Water therapy, tub or shower, has been proven to relax the muscles and relieve pain.  With the relaxation and natural endorphins the body produces in the body of a laboring woman, the cervix relaxes and moves out of the way of the baby's head. 
Now, about 2 miles from the hospital, the phone rang again.  "We need you now in Room 2, in the shower."  "Well, I won't make it, but I'm coming."...

Walking quickly through the doors in labor and delivery I was told, "Your patient just delivered in the shower. "  A million thoughts ran through my head...wishing I had been there earlier but knowing that if I didn't make it on a very short notice I really wasn't needed, I walked into the patient's room to see nurses and techs by the bathroom door, the resident near by, and my patient sitting on the shower seat with a blanket over her, holding her brand new baby GIRL wrapped in a blanket too and loudly protesting being so abruptly evicted form the comfort of her womb.  Just a couple of minutes old and with a first apgar of 8, they both looked great.  By now everyone was taking a deep breath and celebrating what had just taken place.  Mom walked back to bed for the placenta to be born and in a few minutes her baby went to the radiant warmer to be checked out and weighed and measured.

When it was all said and done my patient surely did have the natural birth she had wanted, with very little intervention. She related that she had two strong contractions in the shower and didn't realize at first that what she felt was the baby coming down.  She and the resident assisted the birth of her baby, a beautiful, vigorous little girl who will probably grow up to like showers.  Dad later said, "We wondered why God didn't answer our prayer for labor to start at home.  It's probably good it didn't.  We'd have probably had her in the car." Kudos to nurses, techs and residents who assist mother's having their babies naturally, who can turn on a dime!
"I will make them and the places all around My hill a blessing, and I will cause showers to come down in their season; there shall be showers of blessing." Ezekiel 34:26.
Welcome baby Esther.  May God continue to shower you and your sweet family with blessings!

The Lost Art of Vaginal Birth After Cesarean (VBAC)

 I love my job!  No, I get paid to participate in women's health and empower women to take an active role in their health care decisions and health maintenance.  When I started my career in Nurse-Midwifery the national Cesarean Section (C/S) rate was about 21% and Vaginal Birth After Cesearean (VBAC) was 28% with 70-80% of women who attempted VBAC successfully completing it. 
Nearly one-third  (32%) of all births in 20007 were cesarean sections, the highest reported rate ever in the US(Contemporary OB GYN , May 1, 2010).
Last year a panel organized by the National Institutes of Health in March 2010 recommeded that Vaginal Birth After Cesarean  (VBAC) be considered on a case by case basis in women who have discussed the issue with their physicians (Nurse-Midwives) and are aware of the benefits and risks with the two types of deliveries. The risk of uterine rupture is low, at less than 1%.  Since 1996 the rate of VBAC has decreased to less than 10% in the US. Various surveys have shown that since 1996, approximately 1/3 of hospitals and 1/2 of physicians no longer offer trial of labor(TOL) for women with a history of cesarean section deliveries regardless of prior vaginal delivery experience. Concerns over liability risk have a major impact on the willingness of physicians and health care institutions to offer trial of labor.  Benefits to mother of  VBAC include a shorter recovery period, less likelihood of blood loss, infection, damage to internal organs and less likelihood of respiratory distress after delivery in the infant.
That being said, I had the perfect candidate for VBAC recently. This mother (and her husband) loves her babies and grown children from ages 3 to 21 with a passion and room for yet another child to love.  Being a mature grand multipara ( greater than 5 pregnancies...9 to be exact), she had successfully had 6 vaginal births, then infant #7 had to be an emergency C/S due to a partial abruption ( placenta pulling away form the uterus) during labor. 
As 39 weeks came to fulfillment, her body was agreeing with yet another vaginal birth, but could the dots be connected for the hospital, antibiotics to prevent a possible infection in the newborn, low dose Pitocin, the Nurse-Midwife for support and the physician who would agree to remain in house during the trial of labor for the anticipated vaginal birth after cesarean (VBAC)?  Ecclesiastes 3:1,2a "To everything there is a season, A time for every purpose under heaven:  a time to be born"...
Several phone calls later, the hospital was selected ("Thank you Women's East"), the physician had agreed to come in house for the induction and trial of labor, the spouse and children had been notified, and mom, dad, and two of the big sisters were on the way to the hospital.  When the on-call physician came into the room to meet the patient she thanked him so much and said "I have worried all during my pregnancy, would any one be willing to come and sit with me so I could do this?"  The physician beamed at this mother's appreciation of his time in her behalf. 
With the safety nets of IV access, low dose Pitocin drip, PCN, and electronic fetal heart rate monitoring, the evening moved on.  Slowly but surely the body remembered what it had done so efficiently six times before.  Fetal heart tones remained reassuring as long as mom stayed in a semi-fowler's position. One big sister who had college exams the next day kept in touch by phone or Skype.  Mom enjoyed the loving support of her husband and two daughters during the not quite time for my epidural period and while waiting for labor to complete the task of dilating her cervix to 10 centimeters.

Yes, with just a 21 minute second stage and several pushes, a beautiful dark haired baby girl was born and handed to her mother, umbilical cord cut by one of her older sisters and greatly admired by her father.  This 8th child has a lot of love to experience in the family God has placed her in.  Eccl.3:11 "He has made everything beautiful in its time".."Welcome to the world, Maggie Ann"..you have so much to experience.

Don't Paint the Room!

Every now and then in this age of high technology, what you believe to be solid information turns out different than anticipated.

She was expecting her third child, and already having a daughter and a son, this infant would be the tie breaker.  A 20 week ultrasound strongly predicted a girl!  Big sister was elated and little brother was oblivious to any threat of an additional sibling taking his mom and dad's attention away from his spot as baby brother.  Fetal heart tones during the pregnancy were 156-160s the majority of the time, following the Old Wive's Tale that female fetus's heart rates are higher numbers than male fetuses. 

Since this mother had had two previous cesarean sections, it was recommended for her to have a repeat cesarean scheduled at 39 weeks.  Her bags were packed and "going home clothes" for the new daughter were lovingly arranged.  The cesarean section proceeded as planned and soon the baby's head full of dark hair was delivered through the incision, the mouth and nose suctioned and the remainder of the new infant delivered.  At this point the physician leaned over the drape to mom and dad and said "Was this baby supposed to be a girl?  It's a boy!"  The banter went back and forth..."You're kidding..."  "No, it's really a boy."

Little "no name" weighed in at 7# 13oz and immediately won his parents hearts.  A relative offered to go out and buy the little fellow a new outfit to have his pictures made in, and the laughing and giggling continued for quite some time.

So for the second time in my career a baby was delivered who was expected by the parents to be the opposite sex.  God does have a sense of humor!  Don't paint the room until you hold the baby!

Little Miracles Growing...

Well, it's been 2 months since I checked in and updated you on how the tiny little girls are doing. During Thanksgiving week I had the privilege of visiting them when Mom and Grandma were there. The girls continued to amaze me with their resilience and progress. Olivia, the first born and smallest had graduated to a bassinet and weighed a whopping 3#5 oz.
 

Ava had grown to 4# 1 oz.


During this Christmas season when we thank God for sending His son as a helpless babe to live here and show us how to live,and for his gift of salvation to us, I thank Him for continuing to bless the lives of these two tiny girls and for the plan He has for their future.
May God bless each of you and your loved ones.

God's Little Miracles

It had been an otherwise fairly uneventful twin pregnancy, with mom working full time, resting as she could, gaining adequate weight, and having evaluations with the high risk doctors to closely watch the growth of the babies and be alert for early signs of discordancy, or discrepancy in the size of the babies.  As weeks 25 and 26 came around it became obvious that one tiny girl was slowing her growth and her sister was not.  Mom was hospitalized in week 26, put on bed rest, given steroid injections to help mature her babies' tiny lungs, and daily fetal testing was done.

As the babies entered week 27, the smallest little girl began to reverse her blood flow back to the placenta, which signaled the need for an early delivery of both babies to improve their chances of survival.  How do you prepare a mother for the birth of her babies 13 weeks early?  A cesarean section was scheduled as the safest route for delivery of the tiny girls, family and friends arrived to support mom with their presence and prayers and two NICU teams were present for the birth.

As the skilled OB GYN lifted the first tiny baby girl Olivia, from the womb, she was held in warm towels as the umbilical cord continued to deliver blood and oxygen to her tiny body for 30 seconds.  A tiny cry filled the room,then off to the radiant warmer where skilled neonatologists and practitioners cared for her. Nice and pink, with a small breathing tube placed in her trachea to support her breathing, Olivia was off to a good start.  Weighing in at only 1 lb  6 oz (631gm), she has a lot of growing to do!  

One minute later, the second baby girl, Ava, was delivered, raised a feisty cry, held, warmed, and to the second team of professionals at the second radiant warmer.  Pink, flexing her little arms, small breathing tube placed in her trachea to assist breathing and rest her tiny body, Ava is off to a good start as well.  Being the bigger of the two, she weighed in at 2 lb 1 oz (947 gm).  both babies had little baggies pulled up over their little bodies to help keep them warm.

Being present and assisting the birth process is always a precious gift, but to hear two 27 week baby girls cry and be stabilized and off to the NICU (neonatal intensive care unit) is witnessing a modern day miracle! 

"Before I formed you in the womb I knew you; Before you were born I sanctified you (set you apart)"...Jeremiah 1:5.    
 "For You formed my inward parts; You covered me in my mother's womb."
"I will praise You for I am fearfully and wonderfully made;"  Psaml 139: 13,14.

Thank you Lord, for sharing these two precious miracles with us.

A "Bradley Way" Natural Childbirth

They wanted an unmedicated birth, unless a complication occurred that would require interventions and /or epidural anesthesia.  Having read through "Natural Childbirth the Bradley Way" by Susan McCuthcheon, they were well prepared and trusted Mom's body to respond to the labor process and work with it to welcome their "surprise" baby into the world.

But, oh, the waiting game...Just with walking, Braxton Hicks contractions and daily activities in the ninth month of pregnancy her cervix had begun to thin and dilate until the 39th week found her 4 cm dilated and 90% effaced (thinned out).  Thinking any day regular contractions or spontaneous rupture of the membranes would bring on labor, they waitied,,,

"To everything there is a season, and a time for every purpose under heaven:  A time to be born"...Ecc.3:1 & 2a. Can a pregnant woman be 4 centimeters dilated and not be in active labor?  Yes, she can, and when labor does come her body is very ready to work with it.

Finally after having her membranes swept in the office and going for a massage, contractions came stronger and more regular.  Unlike the false labor, Braxton Hicks contractions, true labor makes you hand the phone back to your husband when the nurse-midwife is asking how often the contractions are coming. 

Upon arriving at the hospital with that serious "this is the real thing" look, she was put to bed for initial fetal heart rate monitoring and having her cervix checked between contractions, was found to be 6-7 centimeters dilated.  With a reassuring FHR strip, the monitors were removed for 40 minutes and intermittant  EFM was done throughout the remainder of her labor.  Sips of apple juice, water, and ice provided fluid intake and a reassuring FHR did not require IV fluids to be started.  Mom was free to change positions during labor which assists the fetus in doing its work of turning, flexing its head and navigating its way through the birth canal.

Mom was supported in a dimly lit labor/delivery/recovery room by her husband's kind and encouraging presence, her mom, one sister, mother-in-law and nurse-midwife.  Her sister-in-law waited nearby and other relatives waited outside of the room.  When a laboring woman's body is not altered by the effects of pain medication or an epidural, it knows how to self-direct pushing.  The work of labor/pushing is off set by the wonderful breaks of rest between contractions. 

Shortly after midnight a vigorous baby boy was welcomed into the world and placed on his mother's chest.  Welcome to the world Henry! God has a special plan for you and has blessed you with a wonderful mommy and daddy.