midwives, looking for advice/explanation for birth...long

[faithfulmama]

hello,
my baby is about to turn 3 and as we approach ttc another, i realize that i have a ton of unresolved fears/questions regarding ds' birth. i would love to hear some input on the situation.

we had a planned homebirth with a very experienced midwife. (ultimately our personalities and her style of managing labor weren't really a match, but i dont' really think this is a huge factor) my pregnancy was very normal, no problems at all. at 41 weeks, saturday, i woke up with bright red bleeding, but no contractions. went to see midwife, decided it was cervical bleeding, no worries. went on to have cramping and more bleeding all day. midwife had another client go into labor, had me do "the trick" which was 2 advil a warm bath and a glass of wine, under the thinking that "real" labor would come on, warm up would go away. next day nothing. wee hours mon morning contractions came on every 5-7 mins. called midwife at 2 am, had me do the trick again, hoping i could get some rest. contractions stopped. started again at 10am, a few 5 mins apart, then 3 mins, 2 mins pretty quickly. for a few hours in the afternoon i "stalled" at 5 cm, so at 6 she broke my water. there was light meconium. at 10 pm i was fully dilated and ready to push. the baby's heart rate had been great throughout labor at this point.

my midwife definitely guided pushing, and i wouldn't say that i was pushing physiologically, though with contractions. a little ways in she noticed a caput forming. the baby descended well with pushes, until a point where she had to push against my sacrum internally until i pushed passed it? also i was definitely fatigued and at a point my lips were turning blueish so she put an oxygen mask on me. after about 1 1/2 hours of pushing the head was crowning. heart tones had been between 120 and 140. i had been pushing in a squat the whole time, and felt the need to move to hand/knees, and she check his heart tones, and they had dropped to 90, so she wanted me back in a squat to get him out asap. he was out in one big push. he had good color but made no respiratory efforts, and he had SEVERE head molding. after suction, stimulation, ambu bagging by midwife, no breathing. ems was called and came 6 minutes later, during which time he had taken a few small gasps. they were able to get him going and he was transported to the hospital. i had to stay back to have a tear repaired. also i had pinched a nerve during delivery and was pretty much unable to walk.

anyway, he spent 2 1/2 weeks in nicu, 6 months on phenobarb because of a few seizures at birth caused by hypoxia, and took 3 months to learn to nurse, (but...thank GOD he is a beautiful, healthy, developmentally normal little guy today!)

i really have no idea what went wrong here. i am a short woman, 5'1" medium frame, and my husband is a large framed 6'3" guy. my son was 8 lbs 10oz at birth. my general understanding is that babies with true cpd don't come out, especially in a normal amount of time. why he would come out and be injured is still somewhat mysterious to me. the doctors in the nicu definitely didn't believe that i only pushed for 1 1/2 hours either.

i have no idea how to approach the next birth. i'm terrified that something like this could happen again, which brings up the topic of where to give birth. i'm also terrified of hospitals and don't want a medicated birth or an unneccesary c-section. but i would gladly take one over a repeat of my son's birth. also i have no real answers or explanations for my family, who is very negative about out of hospital birth, especially after ds' birth.

any input would be greatly appreciated.

[Stephanie L.]

WOW!! That is hard, mama. Hugs!

(I am not a midwife, but a doula) I would guess that was probably a rare and isolated situation.

I just wanted to let you know that you are heard. Here on MDC there will be ideas and support for you. I wish you the best!!

[faithfulmama]

anyone have any thoughts?

[Midwife Kris]

Personally, if I ruptured membranes on a "stalled" labor and noted any kind of meconium at 5cm, I'd be packing us off for a hospital transfer. I have no idea how long it will be until complete, how long pushing will be, and how long the baby will tolerate the stress in addition to how much power mom has in her.

I'm not sure what "advice" I'd offer since I'm one of those who had a pretty lousy first home birth but two more after that. Just do it different (is what I did)... don't try and stop labor with "the trick" if it's going normally and don't try to speed it along unnecessarily. You got the first baby out and Penny Simkin says the job of the first baby is to make the way for the rest of them.

[mothercat]

A lot of times that second birth is so much easier because the next baby is a little heavier and can't do many of the silly things the first one did, like managing to get a hand up over the head.

I think the second babies are trying to be the favorite child and so cause less problems with the birth.

[SublimeBirthGirl]

I'd guess that AROM brought the baby down in a less than ideal position. My little niece was malpositioned, and once my sister got an epidural, there wasn't much she could do to turn her. 3.5 hours of pushing, LOTS of molding, avoided a c-section by the skin of her teeth. I definitely think AROM can cause these kinds of problems.

[bobandjess99]

I think the labor "stall" was probably where it started to go bad.....perhaps your baby NEEDED that "stall" to turn into a better position. Like has been mentioned, by AROM, it's possible the babe was then forced into engaging in a bad position. It's also possible that babe was just a little bigger than your body was able to birth easily....or perhps your sacrum was shaped in such a way as to make the outlet a bit smaller than it could have been? I'm also not a fna of guided pushing in most situations.....simply waiting to push until you got the "i HAVE to push right now" urge might have been a better choice...or not. There's just no real way to know.

[OHmidwife]

I don't have time for a long comment right now, but I had to say this: DO NOT take Advil (or any ibuprofen) during the third trimester of pregnancy or during labor. It can cause problems with the baby's heart. Read here: http://www.otispregnancy.org/pdf/Ibuprofen.pdf

[Jane]

I think that you could plan a second home birth with some definite limits on it - you could choose to transfer if there was any sign of meconium, for instance. Or have more heart rate monitoring, even continuous if your midwife had the equipment. Or, my suggestion would be to refuse pharmacopia at term, the wine, any herbs, the ibuprofen. While I hesitate to "BackSeatMidwife", I don't think it's fair to try to stop your labor when you are 41 weeks. Even if there is another woman in labor.

There is a growing amount of evidence that some hypoxic brain injuries like cerebral palsy are pregancy events, not labor/birth events like many lawyers win cases on. There are no answers there, though, as it seems that there aren't signs or symptoms to detect. It's possible the hypoxia occured days or weeks before birth, or that it occured in labor or pushing, or after birth when he didnt want to breathe. If you haven't got answers after a 2.5 month NICU stay, I'm not sure there are answers for you. I can't imagine how you must have felt during that time post partum, but without your baby at home.

I do think that the amount of moulding before labor can be underestimated. I've seen some planned c-section babies that had significant moulding.

I am glad your son is okay now.

[faithfulmama]

I wanted to add a few things. Since posting, I have talked to a few midwives about our situation. One had an interesting suggestion for a possible cause. She asked if I had been bleeding during pushing, which I had, not profusely but I definitely remember it dripping on the chux pad underneath me. She said that it sounded like it could have been a partial placental abpruption, which I would explain the hypoxia. I am curious if anyone has had any experience with a similar situation.

[MsBlack]

It sounds to me like all in all, there was simply too much intervention in your birth. As others have said, there is no way to know 'when' hypoxia occurred...but because of this possibility (and other bad things), I am very leery of the kinds of things your mw did. It almost reads as 'cascade of interventions' to me.

"Stalled labor" does not worry me if baby is doing fine--there are reasons for these things, and most often it is wisest to trust the wisdom of the body. That is, the wisdom of the mother and baby's bodies separately and together to work out the necessary details of safe birthing.

I really hate AROM and have never done it. I suppose someday I'll believe it really is necessary in a particular situation, but from the stories I hear from moms and mws both, it is done WAY too often. Between risk of malpositioning, cord prolapse and infection, it seems to me something to avoid if at all possible.

Next time, find a mw who trusts nature more...who is more comfortable with patience, waiting, and mystery....and with whom you can fully relax without handing over all your power. And do more research, so that you are prepared to knowledgeably consider any suggestions that your mw might make. NOT criticizing here! Just saying, for instance, that if you'd known more about both AROM and 'stalled labor', you might have refused the AROM and perhaps been able to see the 'stall' as instead, a welcome rest and/or prep time for baby (I have seen labors start and stop and start up again; I've seen labors proceed for hours with little apparent progress only to end quite well in due course..never have seen a 'stalled labor'...KWIM?). We can learn so much from scary or negative experiences...I hope from this you are able to learn all that is necessary to bring you to your next birth more power, confidence and trust in yourself and birth.

[MsBlack]

Hmm, needing to add--

When choosing a mw, be sure to ask how many births she is contracted for during your due date period. Be sure to ask, however many other births she is contracted for, HOW FAR APART the moms live from each other. Be sure to ask whether or not she has able-enough assistants and mw backup, in the event of more than 1 mom in labor.

In our region, there has been much trouble and angst over a mw who was taking on 6-10 births a month over a 5hr driving span...and mostly working w/out any assistants or solid backup. She did have an apprentice--but one who was only helping with 1-2 births a month. She did know other mws--but rather than referring some of her new-client calls to these other mws so as to keep her numbers 'doable'...and rather than notifying parents or other mws in advance, and arranging meetings btwn clients and other mws just in case she couldn't make it to a birth, she would wait until she had 2 or more in labor and THEN call to see if any other mw could cover for her. She occasionally even demanded that the 2nd mom to go into labor come to the home of the 1st--without ever saying in advance that this might happen or introducing people to each other.

Needless to say, she has missed quite a few births. And needless to say, being that stretched thin, she tends to do inductions, AROMs, internal manual manipulations, and other stuff to make labors go faster and births more convenient to her own timing. She also has quite a few transports--some, just the people who refused to go to some other fam's home to give birth, or who got tired of waiting for her to arrive while they labored. Some, for issues like yours, where altho it is impossible to say 'when or why' hypoxia or other bad things happen, it can be guessed that her actions could well have had something to do with it.

Anyway, something about your post reminds me very much of our 'troublesome mw'...and while your mw may not have been much at all like the one I mention, there are certain similarities that prompt me to add these things to my response to you.

[Paige, CPM]

Dear Faithfulmama,

I think that you can surmise the cause of what happened to your precious child but you may never really know and judging the midwife may be putting blame on someone else for something she may not have caused...she might have but will you or her ever really be able to say? I do not think it is helpful or healing to do that if you do not really know what caused the problem. We are feeding into blame here on this forum and you have even experienced the nicu docs, not believing you pushed for 1 1/2 hrs and wanting to blame it on that. All of this feeding into blame could end up as blame on you...for homebirth or choosing that particular midwife and I do not think it is helpful.

Who knows, your water may have broken 5 min after she broke it and the same thing could have happened, IF that is what even caused the problem. Light mec, many people would not transfer solely based on light mec; even with a longer labor...some might wait to be guided by the fetal heart tones in that case.

For whatever reason (intervention or not) your baby's heart was reacting to the stress of being born, which can happen in the best and most low intervention of circumstances as well. Stuff does happen and we can not always predict or control it. This is an important point I always talk about with prospective clients and during the occasional prenatal.

Would it be helpful for you to review the chart with the midwife? A person with an open heart might sit down with you and go over everything and tell you why she did what and the pros and cons, theories, etc... and that might be healing for you and maybe for her too. Have you tried this, or would you consider doing this?

What is your intuition telling you? Is saying you made a mistake by having a home birth or is that feeling from other people around you not being supportive about homebirth...if that is the case shame on them for trying to blame you. You are a loving, intelligent mother and homebirth is a great, statistically safe option for many women and it sounds like you fell into that category. Many many interventions happen in hospital and bad things happen there because of this and sometimes random stuff happens in the hospital that you can not blame on a provider.

But if you choose hospital for the next time no one should blame you...you have been through a lot and may want the option of a tertiary care center / nicu team just in case. But then it could be so hard because then it might appear you are giving into what unsupportive people believe about homebirth. But don't listen to anyone but yourself. Try not to discuss it with these folks. Maybe you could discuss it with a therapist who specializes in reproductive counseling?

Whatever you decide, take heart that first and second births are usually very different. I hope these random thoughts are helpful...I can only imagine it is a lot to have been through and you have my greatest sympathies.

I hope you find a care provider that will take care of you the way you need and you have a happy, healthy and healing pregnancy and birth! Paige

[MsBlack]

I agree that engaging in blame is not the most productive of things for anyone concerned. And, it can be very productive indeed to learn that there are many different ways of doing things...different kinds of midwives...different approaches that can be taken by both midwives and moms/families to birth. I also know that we are generally not too worried about considering things like 'cascade of interventions' when discussing a hospital birth, and the place of those interventions in shaping the tone of a labor and the outcomes. While it is important to understand the midwife's point of view in coming to understand events and 'possible reasons' for all that occurred at this birth--rather than simply judging blind--it is also important to understand that the term 'homebirth midwife' does NOT imply only ONE kind of attitude or care. Exploring all of that, I think, CAN be productive for anyone hoping to heal from a scary experience and looking to move into a new pregnancy and birth sometime soon. Any mom needs to feel firmly that her midwife's personality is a good match for her own, and that her midwife's style is a good match for the family's goals and wishes at birth.

To be clear, I do not and could not say that the mw 'caused' any problems at this birth. I can and do say that her style, as reported, seems to place much confidence in what she can 'do' for a mom/baby, and little confidence in a mom's ability to birth normally under her own power and intuition. I do say that the things she suggested, even 'the trick', seemed needless and more likely to interfere with mother/baby's work rather than supportive of it. All this is NOT said in the hopes of faithfulmama simply placing all blame on her mw and moving on--but rather in the hope that this mother will be able to see where she might choose differently next time: not just choose a different mw, but a different attitude and sense of power for herself--which is, after all, the foundation of any pregnancy/birth.

[mwherbs]

the bleeding as first sign of labor / prodromal labor sort of put me off a bit -- how much blood? where was your placenta? since you baby is doing well I don't think that the baby was without oxygen for too long- did the mw do chest compressions too?

you mention abruption and maybe or maybe low lying placenta with a very small margin- the thing is that low lying placentas also tend to have a cord that inserts on the side of the placenta rather than central ,velamentous insertion- then the cord could be compressed enough to cause distress, as the baby descends-- I also agree that in the presence of mec and unusual labor pattern in a primip is enough cause for concern to consider transfer- now if I saw mec and your labor just chugged along probably wouldn't think much about it-- especially at 41 weeks because late babies have more benign incidence of mec just from size and the full squeeze rather than a release caused by distress. but this is all still timing because mec can bring on wear and tear of surfactant and is a source of food for infection-- from 6 pm to 10 pm you were fully dilated- that is pretty quickly-- now I usually wait for baby to decent -- you were 10 but what was baby's station- how deeply engaged was the baby, -1,-2, +1, +2?

a 2 1/2 week stay in NICU a small regional hospital or a big medical center? - why did your baby spend this amount of time in the NICU, weight gain, infection, the seizures other problems?
I have some concern about repeated use of ibuprofen -- I don't know what amount is transferred via diffusion or active transport across the placenta and membranes, in breast milk the levels are relatively low less than 1mg so that would be relatively safe but the levels could be higher crossing to a fetus if they are higher one or 2 doses could be enough to cause a premature closer of the ductus -- studies in 2003 show that for born babies with patient ductus- they tried using a loading dose of 10 mg/kg with 2 - additional 5 mg doses and successfully treated/closed the ductus with a 95.5% success rate-- actually pretty good for babies on the outside needing help but not before birth.

none of it sounds like repeating cause, this was a first birth for you right, so they are usually longer and harder- second births are easier partly because you know what to expect and partly because the baby has stretched parts as well as put grooves into your pelvic bones.

[faithfulmama]

mw herbs:
as for the bleeding that started a few days before ds was actually born, i am not sure of the actual quantity, it really seemed similar to a period, cramping and all. the birthnotes from my midwife say blood lost during labor and pushing was 2-3 T. It certainly wasn't profuse, but it seemed like more than that. Of course blood always looks like more than it is, especially to the untrained eye. The placenta was normal with a central insertion of the cord.

i'm not sure what his station was when i started pushing. before i was fully dilated i was having uncontrollable urges to push, but i don't think i was when i actually started pushing. i don't remember it feeling "physiological". it was definitely coached.

she didn't do chest compressions, just breaths with the ambu bag and mouth to mouth i believe. his heart rate stayed good after delivery. i'm not sure how long he was without oxygen. he had a few non-reasuring cat scans and mri's, but by the grace of god he has never been behind on milestones, or needed any additional therapies. (aside from being a late talker, which my dh was as well, and his receptive language has always been on target. ) we were discharged from follow up with the pedineurologist when he was 18 months.

as for my son's stay in the nicu, he was at a major medical center. his stay was so long because of respiratory and feeding issues and weight gain. he had iv nutrition for almost a week through an umbilical line because they didn't want to stress his digestive tract i believe, also on the premise that his urinary output was abnormal and his kidneys and other systems had sustained some injury from the hypoxia. also they were worried about his gag and suck reflexes which were apparently abnormal. then he was given breastmilk through a gavage tube very slowly until he could handle a tiny amount of milk, then by bottle (major mistake on my part). it took him that amount of time to be able to take his feeding within 30 minutes, which was the rule in the hospital. he had a really weak suck and was very drowsy, undoubtedly because of the seizure meds. also he was losing weight and had to have gained a certain amount. and it was also at least a week before he was breathing regularly and totally independently of additional oxygen or positive pressure.

that is interesting about the ibuprofen. clearly there are some things that i would never do or consent to again. ibuprofen and arom being a few.

[mwherbs]

actually the AROM which I rarely do doesn't seem to have been much of a problem causer--- I am thinking that your baby may have had MAS the hospital stay for breathing is what makes it seem like that was the problem- and MAS is not a birth accident- it is now considered to be a problem some time before birth also heart rate is another pointer to MAS--

[faithfulmama]

mw herbs: so MAS can happen before birth, and you can still have good hearttones during labor? it seems like the nicu would have given a specific diagnosis, but they did say that his lungs were having problems inflating, similar to a preemie baby. also it took awhile for him to have normal o2 saturation without additional oxygen. it makes sense.

so other than him being overdue, should you have any other warning signs for MAS?

[mwherbs]

MAS is mec getting into the lungs before birth- the guess is some form of hypoxia happens during pregnancy that causes the baby to release mec- and to be honest there is NO current way to tell- yes heart tones can be perfect at the time of birth- and it is a fairly low incidence of when mec is present that it causes MAS-- when it makes an obvious problem is when the baby tries to breath -- that is why in the past they devloped all sorts of suction routines- but what they figured out was suctioning doesn't prevent MAS because the suff has gotten into the lungs and done the damage already- by wearing down/using up surfactant and by causing a "chemical pneumonia" by making some inflammation,meconium is not just old dead cells- it also is bile salts and possibly some digestive juices too and there could be infection- sometimes it is an infection that may trigger an event and sometimes infection occurs because presence of mec degrades the infection-fighting properties of amniotic fluid and an infection starts--
we had one baby with very very mild MAS and the first thing they did was intubate and put some surfactant in - I guess at the time that this is not a general standard but something that some Neonatologists do- and it made a huge difference- and yes with the compromised surfactant the baby was acting like a preme--
got to run...