the births of Noel Stephen & Linus Patrick
In the early evening of July 19, I spent some time online, sitting on my birth ball at the computer. My husband called me a couple of times for dinner. I stood to respond (it was 7 p.m.) and the cramps began when I rose to my feet. I was so happy to welcome them again after nothing! I went to the bathroom and noticed "bloody show." Walking down the stairs, I told Joe what was happening.
As I sat at the table and tried to eat my dinner, the cramps continued with regularity and vigor. At one point, I asked Joe to time them, and I began to realize that there really wasn't a break between them. They continued in a seamless wave of surge-peak-receding followed by another surge and peak, which started before I could distinguish an end to the first set. There was no time between when I wasn't contracting. They were lasting about 2 minutes with no break in between. I thought that was kind of strange for beginning labor, but then I really am not quite the labor jock who remembers all the details about what is significant about how long & how frequent contractions are....
I was using my Hypnobabies training to relax around the surges and that made things manageable, but it all felt a bit revved up. Then again, that's what I was hoping for by welcoming the contractions as muscular and relaxing around them: that the lack of interference would let them accomplish their aim most efficiently.
In addition to things seeming "revved up," I had a weird concept of time: an hour and a half felt like 15 minutes, even though I could see from the clock how much time had passed. I was aware (by the clock) of the passage of time, but it all felt much slower.
Remembering how long my labor with my first child had been, I wasn't sure what we were in for.
I believed this was the real thing (more bloody show that was disconcerting enough that I had to look it up online to see if it seemed within the range or "normal" or if it was more "concerning," but it seemed okay) but I wasn't sure if I was starting from a very firm & closed status or if the cramp-like contractions on Wednesday had accomplished a lot in terms of effacement progress.
I was thinking about booking a hotel room to labor in and dropping off our daughter with friends on the way (again, I believed this was the real thing, though uncertain about how far into the process we were, overall) and I wondered if my primary care physician (our family doctor) would be willing to meet us at her office and check my cervix, giving me an idea of whether we were progressed enough to go to the hospital then, or whether it was going to be more of a long haul type situation.
We were about 2 1/2 hours into labor. I had gone upstairs to lie down at this point, knowing that my pillows would help facilitate more complete relaxation around the contractions. This slowed things down a tad, but not in a big way. And honestly, I'm not sure if things really had gotten easier, or if my relaxation was more effective (making things easier) in the supine position.
I was listening to one of my Hypnobabies CDs while Joe called my primary care physician at home. He spoke to her husband, who said she'd had a long day and was exhausted; she had gone to bed at 7 p.m. and was sleeping.
Joe relayed this to me, and we began discussing logistics such as packing the car and calling the friends to arrange for our daughter's care. Before too long the phone rang. It was my doctor! Joe talked to her for a bit and then gave the phone to me. I figured she was doing the old trick of seeing if the laboring mom could talk through contractions, and I wondered if the effect of my Hypnobabies training would disguise things at all, or give a "false read." I was pretty calm, a little distracted/fragmented, and I told her how things were going and narrated the contractions as they came and went. I also talked about how I was considering going to a hotel to labor, since I wasn't keen on being at the hospital if I couldn't use the most effective of their supports for natural labor, but how I'd like to have an idea of where I was at in terms of cervical progress before making that decision. (She lives in the same town as the friends who were keeping our daughter for us, and her office is very near her home. I thought maybe she could meet us at her office and we could swing by there after dropping off O. I didn't actually ask her this, but I was hoping.)
She basically said, just call the on-call OB for my doctor's practice, and that it sounded like I was in active labor and should go to the hospital. She said especially with twins, it wouldn't be that great to surprise them, especially if they were short-staffed that night and needed warning to call in extra nursing staff. I expressed my disinclination to labor long there stuck to monitors, but she seemed to think we could use telemetry if constant monitoring were necessary (I mentioned that Dr. P had changed her tune on that and told me it "wouldn't work well with twins" just in the last two weeks.)
I already knew that the on-call OB was one my doctor specifically had recommended against using back when we'd just learned I was carrying twins and I was trying to figure out my medical care. She had thought we wouldn't vibe well at all and she'd been frank with me about why. She was pretty quiet when I told her he was the on-call physician. (I mean, what could she say at that point? "Oh, I'm sorry to hear that"?) She did ask me if my OB had said she'd come in for me, being twins, whether she was on-call or not, and I said that actually, she'd said she wouldn't be available that weekend.
So....we called the OB's answering service, then went about with our last minute preparations: me laboring, Joe gathering the bags. The answering call came back, with instructions to go on in to the hospital and report to Women & Childrens. We loaded the van and I took a minute to confirm my hypnosis & to raise my "lightswitch" to the center position, so I could walk and talk without leaving hypnosis, and I walked out to the van and curled up on the back seat around my Snoogle body pillow. I had the CD player and headphones, and I listened to another Hypnobabies CD as we rode into town.
All in all, a fair bit of time had passed since we'd called and said we were going to be heading in. We got to the hospital sometime after 11 p.m., and someone met me with a wheelchair and took us upstairs, got me to a small room with two twin beds (not one of the nice birthing rooms), checked my progress (I either was 2-3 cms or 3-4 cms...I can't remember for sure and neither can Joe, but I think it was 2-3 because I remember being unimpressed), and hooked me up to a monitor. I think the test strip was pretty good.
They left me on the monitors until the doctor got there, and someone brought in an ultrasound machine to be ready for him. Joe had my Hypnobabies discs playing, but the CD player was on the other side of the room and though I could hear it, it wasn't front and center for me.
Dr. M, the on-call OB, was high-energy and very bulldozer-ish. He basically came in the room, introduced himself, announced that I had monochorionic twins with a breech-presenting second twin, and said we had no real choice but to have a vaginal birth with Twin A and then a c-section with Twin B (since he still was breech.) Or else, of course, to have both delivered via c-section. I challenged him with the info that Dr. P was planning to try an external version on baby B after twin A was born, and that none of the perinatologists in Albany had questioned the goal of a vaginal attempt for both twins.
He said no way should a version be attempted, that babies don't turn vertex even with more room in the womb and there's not time to wait for that possibility, anyway. (He kind of blustered through his reasoning against external versions, and I don't remember all of his "babies don't" rationales.) He said a version is risky for a breech baby. He said the only legitimate possibility would be a breech extraction (when the doctor reaches in, grabs a foot, and pulls out the baby. Not to be confused with a breech birth, when the mother pushes out a breech baby.) He came back with stats and studies, including one currently still underway in Canada that we'd heard of from one of the perinatologists, after which nobody was going to question c-section for a second twin who is breech. (Again, he was blustering/overbearing and his train of thought was not very easy to follow at this point, at least not while I was in labor, but he obviously was trying to pressure/influence/convince us.) He blatantly and clearly said we were jeopardizing our babies and not choosing in their best interest if we refused the c-section.
He then said we had the right to ask for another physician or to refuse his recommended treatment. We asked for time to talk. Everyone left the room.
The "good" thing was that in order for him to do the ultrasound to confirm fetal positioning (and baby B still was breech), they'd turned off the fetal monitor. And nobody hooked it back up. While they had left us alone, I pulled off everything that remained and pulled the velcro straps out from under me in hopes that that would be that for being tied to the machine.
I'd been contracting that whole time, and found it really hard to keep my "pressure-sensation" only contractions (thanks to the Hypnobabies training) while he was in the room. They were more like pain sensation contractions, and I was resisting and practically writhing on the bed through a few of them, due to the tension of his "vibe." I did not feel phased or frightened by his words, though, just stymied by how I was going to birth there with that obstacle in my way.
I told Joe that we should ask him or one of the nurses to page Dr. P and see if she was available, and if not, to ask for a transfer to Albany Medical, where the perinatologists with whom we'd worked were based. Joe went out to talk to Dr. M (I'd said I couldn't labor effectively if I had to be involved in the negotiations.) Joe told me didn't get many words in, but the guy asked why we were so against c-section, anyway, since it was our "safest option" at this gestational age....practically no-risk. Joe gave him a few reasons. I know he was under a lot of pressure. The doctor said there was nobody else available to deliver. Joe never got to bring up the question of transferring, because the guy was so take-charge in the conversation. He asked Joe, "So are you going to do this? Can I prep my team for surgery?"
Joe said he'd talk to me, and he came in and relayed all this to me. I know he was shaken and he said maybe the c-section was the right thing. I still was feeling calm and certain without self-doubt on this issue, albeit upset about what was happening and distressed about Dr. M attending the birth. But I had the Hypnobabies training to help with my centering. I was listening to the Twin Birthing Affirmations that were so familiar to me, and continuing to contract. I was thinking hard about what to do.
The doctor came in the room a bit later and I asked about transfer to Albany, and the doctor basically said it was against the law for him to transfer us because I was in active labor (2-3 cm dilated was his assumption based on the pelvic exam just before he talked to us, but I knew/suspected I was progressing fast.) I clarified that getting to Albany would be a matter of us checking ourselves out of the hospital and going to Albany on our own steam, and he said that was right.
I asked him about giving the baby a chance to rotate, and he dismissed that idea. He said something about "babies not doing that" which made about as much sense to me (since I've talked to mothers whose babies did exactly that) as "your twins are growing big and twins don't do that" which I heard multiple times from one of the members of the perinatologist team. I asked about breech extraction, and he said if we refused a c-section, that's what he would do. He didn't think it was best for the baby, though. He mentioned that if the baby was in distress or not tolerating labor, or if cord prolapse or placental abruption was an issue, c-section was going to happen. I said that had been my assumption all along; I just was not convinced that it was necessary to plan it ahead of time.
At one point, he said, "You are high risk. You are a high risk pregnancy. Humans are not supposed to carry twins; humans are supposed to have one baby at a time." I got the impression that he honestly felt I was being stubborn out of ignorance or something.
I didn't say anything to him (I still was contracting and working hard to stay relaxed, muscularly, around my uterus and its work. "My job is to relaaaax," I would whisper to myself anytime my mental activity got in the way of relaxing around the process.) In a way, I knew what he was saying: humans aren't meant to have litters. But I had a sense of assurance that basically dismissed his comments, or at least displaced them. These were spontaneous twins, and the rate of identical twins worldwide across cultures and races has remained constant, and he was telling a woman whose cervix had remained firm and closed at 38 weeks that she was "not supposed" to carry twins when I knew I was carrying my babies to term in such a healthy way. The other thing was that I was going to have one baby at a time, as every mother of twins does: I was going to have two births.
He also brought up my file, which he'd been reading, and said that Dr. P had written that she'd advised me that I had a 60% chance of having a c-section for the second twin. He brought it up in a "your own doctor told you you had a very strong chance of having a c-section. Why is this a problem?" sort of way. I told him I wasn't sure she'd mentioned percentages to me, but that she'd reiterated the possibility (probability?) multiple times; it still wasn't the same thing as consenting to a c-section for the second baby in advance.
He told us to let him know our decision.
I had a bunch more contractions, relaxing ("My job is to relax") around them and hoping that this was allowing the uterine muscles to work double-time. This was so different than my labor with Ocie....I felt very little resistance to the journey, to what was happening in my body.
My response to the contractions this time wasn't perfect because I didn't have great pillow support on the bed to relax as well as I wanted (physically.) I'd packed my Snoogle pillow for that purpose, but I puked on it in the car, so that was a no-go. I needed two pillows for my leg, and not really "between my knees" the way the nurse had put it, but stacked a little in front so the top leg could rest on them while the bottom leg was just behind, and a lip of pillow for under my belly so I was comfortable and relaxed on my side. But I was making do with what we had.
I was starting to feel overwhelmed, though, and thinking things like, "Shoot, if I am going to end up with a c-section for baby B, why not just give in and have them both by c-section? Then this will be over." The thought of going through all the labor contractions, then the pushing, knowing that I had abdominal surgery in front of me (I had the irrational conviction that even if we agreed on an attempted breech extraction, the doctor would pronounce it impossible no matter what when the time came and I'd be having a c-section), just felt like too much. I felt afraid and betrayed and pessimistic. The thought of a c-section was upsetting and scary but a little seductive.
But part of me said, "I'd better ask for a vaginal exam, because I bet I'm in transition if I'm thinking this way." (Bless myself for learning from Ocie's birth....I'll always regret that I didn't ask to be checked one last time before transferring up to the LDR floor from the alternative birthing center, since it was almost an hour of waiting since making the decision to go up, and I'd continued contracting the whole time. When I got up there to be hooked up to pitocin, I was in transition, and I bet I'd have been able to stay down in the birthing center and have more of the birth we'd wanted if I just realized the signs, and asked to be checked, at the time. But, that regret served me well last night.)
I did tell Joe my thoughts (about having both babies by c-section), but acknowledged that it was mostly because I felt dejected at ending up with it either way, and the thought of going through all of labor with that ahead of me was challenging. I also said that I knew that laboring was good for my babies regardless of how they ended up being born, so I shouldn't just decide to do an end-run around the process even if the end result was going to be c-section. I also mentioned that I thought maybe I was in transition, though I couldn't remember when that typically come (the last 2 cms dilation or what?)
I asked the nurse to check me next time I saw her, and she did so and ran out of the room, saying, "I think you're complete; I have to get the doctor."
He returned with her, gloved up, and did an exam, saying "We have to get you to the O.R., you're ready to have this baby, the head is right there."
We never had given him our decision, and I was mindful of that but decided not to bring it up. Classic Amy.
I kept my eyes most of the way closed so the switch from dim birthing room lights to hallway & then OR lighting wouldn't shock me too much. Joe left the CD player back in the room so I didn't have anymore Hypnobabies to listen to even though I'd been counting on the "pushing your baby out gently" CD for guidance during the pushing phase. (I didn't send Joe back when I thought of it because he'd already scrubbed up and I wasn't sure if leaving the room would be problematic or not.)
There were so many people in the OR. The anesthesiologist sat near the head of the table through most of my labor with the second twin and basically kept his eyes averted, and I realized later it probably was to preserve my modesty because during much of the pushing I ended up upright on my knees facing that end of the table, and I wasn't wearing anything. At a certain point before the first twin's birth, Dr. M sent the surgical team out to give them a break, but told them to stay close so they'd be on hand for the second twin.
I had rapid-fire contractions and couldn't find a break to move from the bed (I'd rolled in on) to the table, but they kept telling me that I needed to, so I eventually did. I said I didn't want to be on my back (the OB said he only needed me there for the breech extraction--which we'd never finalized, but I guess he assumed we were set on that) and I tried being on my hands and knees for awhile. I felt lots of pressure but was waiting for the urge to push. Finally, I tried some tentative pushes...nothing obvious to anybody else.
I waited for the birthing waves and pushed gently and gradually started to "feel it." It took awhile. I ended up moving upright on my knees, with my arms hooked around Joe's neck/shoulders and those of the nurse beside me. I didn't ask her; I just did it. I pushed pretty hard, at least when I could feel it, and also tried "breathing out the baby." I ignored instructions from anyone else (mostly the nurse, who offered low-key coaching from time to time), though I did consider if it "felt right" to me and sometimes I did what she suggested for the next "pressure wave." (Guess she was being considerate of the fact that she knew we were using hypnosis...she kept saying "pressure wave" instead of contractions!) Back in the other room, she had complimented us several times on how beautifully we were laboring together, and yet she'd still be shocked at how speedily I'd made progress (she was the one who'd checked me.)
The hypnosis worked well for me, as far as pain management. I definitely felt I was experiencing the “comfortable vaginal twin birth” I’d been preparing for. But it wasn’t easy, exactly. It felt a little like things were out of synch, or a little bit willy-nilly, in terms of the productivity of my pushing. I’d been counting on having the “pushing phase” disc to listen to, but I didn’t have that. Maybe it would have helped to economize things a bit. I have no sense of how long I was pushing; it seemed like a “long time.” Joe estimates it was about twenty minutes; I don’t know if he is right.
I felt the ring of fire but it was distant, a sensation that didn't feel exactly painful, just a ring that I "recognized" (in a “hey, that’s the ring of fire” way) and I pushed through it after a moment. I didn’t think about pushing gently or incrementally; I just bore down. Noel's head was out, and then his body burst out in a tumble. I'm not certain if anyone actually caught him, poor little guy. They clamped and cut his cord immediately, and whisked him over to the warmers to check him out. The doctor had been sitting quietly nearby during the whole birth, not doing anything apart from offering perineal support (with olive oil) one time, and keeping up with the intermittent monitoring. I was grateful to him for his low-key role at that time.
After Noel's birth, he sprang into action, calling back the surgical team, saying I had to turn around and get on my back, with my legs elevated. I took my time, partly because maneuvering on the skinny O.R. table was SO awkward, and partly because I was exhausted & uncomfortable (and freaked out by the metal clamp dangling down and swinging--the clamp at the end of Noel's umbilical cord), and partly because I wanted the time to meditate/communicate with Baby B and remind him "head down, facing back, chin to chest." AND give him time to begin to turn. I told him he had lots of room and to USE IT to improve his chances of a safe vaginal birth. (Breech extraction has its risks, and it never was my first choice for birth, albeit more desirable to me than a c-section.) I also did my finger drop Hypnobabies technique, trying to center myself against fear and uncertainty.
I finally got into position and the doctor reached in. I don't remember feeling anything. What he said then is a blur, but I think he did try for a foot and realized the baby had slid transverse and was on his way into a vertex lie. I'm not sure if he (doc) manually manipulated that process anymore, but I know he called out, "We have a cephalic presentation!" in a very excited voice. Joe confirms this, that he sounded manic and giddy. [I saw him briefly when we were leaving the hospital, and I asked him what happened. He said, "I turned him." (He was all smooth and glib and matter-of-fact at this point. It made me wonder if I'd imagined his tone in the OR.) I pressed for more details, asked if the baby had turned transverse or was turning and he said yes, the baby was transverse and he reached in, got a foot and the baby easily turned vertex.]
After a few pushes, I said this position was crazy and that I wanted to get upright again. The doctor, bless his heart (because the attendants seemed to look to him for "permission" at that point), said, "This is a vertex vaginal birth. She can use whatever position she wants." (This is sort of what he said when I first got to the O.R.--that the first birth could happen however the mother wanted. That it was the breech extraction that he needed me to be on my back.)
So, I got upright, moving gingerly again. The contractions didn't start up right away. When they did, I didn't really feel the urge to push (I think it was because the baby's head wasn't really engaged yet, or something regarding his positioning.) This was a little stressful to me because before the birth, Dr. M had been harping on "no more than 15 minutes between babies, because of the shared placenta. Too risky to go longer," and I felt I was going to run out of time based on his clock.
I don't remember the same kind of pressure that I'd felt before, the feeling of an impending poop. I pushed hard, but it felt random to me. I kept looking over to Noel under the warming lights, and he was so calm, staring up and looking around. I felt upset that he was alone those few feet away, and that I was missing his calm, alert period. I also felt fearful of being too tired to get Linus out, and that I'd end up having a c-section. I am not sure if the sensations/urges and my pushing efforts ever got synchronized. I know that I pushed hard.
The intermittent monitoring did not seem to come very frequently, but things seemed fine the couple of times they checked. Then they checked again and had trouble finding a heartbeat. Or they weren't certain that it was the baby's heartbeat and not mine. I remember that the anesthesiologist grabbed my wrist and waited quietly, counting, then told the doctor my pulse rate. I'm not sure if it differed from whatever they'd found with the Doppler, but things got very stressed at that point.
Dr. M called for me to turn around and lie down. He said that he didn't have a heartbeat, or that he couldn’t confirm a reassuring fetal heart tone anymore, and that the baby needed to come out right then. I wasn’t sure if they had gotten no heartbeat on the Doppler, or if it was that they weren’t certain whether the heartbeat they heard was mine or the baby’s. I also wasn’t sure if the pulse rate that the anesthesiologist got from me confirmed that it wasn’t my heartbeat they’d heard on the Doppler, but that the baby’s rate was “unreassuringly low.” Or if, indeed, there had been no heartbeat found for the second twin. I didn’t try to ask what the scenario was; I just asked what he was going to do. He said he was going to assist in getting the baby out via vacuum extraction, and he barked at the nurses to help me get my legs up. Joe held up my left leg.
All of this pretty much was a blur after the fact, plus I waited too long to try to write it down. But I think I pushed, and he used the vacuum. I don't remember feeling anything at the time, and suddenly the baby was out of me, on the table. I could see him. He wasn’t really moving, and he wasn't pink. I wondered at the time if it was vernix on his skin, which is what it looked like, or if he just was lifeless and gray or bluish. I never thought things would end badly, but I wondered if he was okay. Joe was similarly concerned because the baby seemed stunned or dazed to him, but he saw him move and make a sound within seconds, and he immediately assured me that the baby was okay. Dr. M yelled out for some piece of medical equipment, barking about having asked for a second set, and the nurses sort of fumbled around. He said he’d do it himself. I think it may have had to do with clamping the cord.
They took Linus to the isolette next to Noel and by that point we could hear him crying and see him kicking. His ferocity was such a contrast to Noel's wide-eyed and round-mouthed (a little "O") calm. I told Joe to go over to the boys and I turned back to attend to stage 3 of labor. Dr. M mentioned to me that there might have been some transfusion between the twins, but that if that was the case, the second twin was the “recipient” rather than the “donor.” He suggested that this may have served the baby well at the end (by giving him “extra” blood which may have balanced out whatever distress he was in.) There really was no obvious sign of TTTS, though. Twin B had more red blood cells than his twin, but neither twin was polycythemic and Twin A was not anemic.
I did end up with a hemorrhage when I delivered the placenta, and ultimately when my iron levelsw didn't rebound, and kept dropping, I had a transfusion (2 units of blood) the next day.
By the time I got into a bed from the table and they wheeled me back to the room where we’d started out, I was fading fast. I kept thinking that I wasn’t going to be able to hold the boys, let alone keep my eyes open to look at them and focus on them, because I was so weak and tired. They had gone to the nursery and Joe had stayed with them, both to be with them and to make sure our wishes were honored as far as the newborn procedures go. He brought them back to the room so that I could hold them for the first time, and they spent what was left of that first night sleeping with us. I was, indeed, exhausted and weak, but I lay there looking at them. I did nurse them, too, though I don’t remember much about that.
The thing I remember is that from the start, postpartum, I felt joyful and empowered, and as soon as I’d rested and started to rebound from the blood loss, I felt completely able to focus on the babies. This was a sharp contrast to my experience after birthing my daughter, when I felt so much distress about the birth. My need to process it and to heal emotionally almost distracted me from bonding with her; it certainly conflicted with that focus on her. This time I wasn’t focusing particularly on how empowering the birth experience had been, but the satisfied feeling was a foundation for my focus on the twins and I was “moving on” into mothering my newborns without effort or conflict or distraction. That was so wonderful.
Noel Stephen was born on Sunday, the 20th of July at 2:20 a.m. He weighed 7 lbs and ½ ounce, and was 19 inches long.
Linus Patrick was born on Sunday, the 20th of July at 2:50 a.m. He weighed 7 lbs and 11 ounces, and was 20 inches long.
The twins were born at 39 weeks and 2 days gestation, the night after the full moon.