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!