What if you never saw a birth like this?

One of my readers, doctorjen, submitted this birth story for the book giveaway. I am reposting it here with her permission. She is a family practice physician who works in a small rural hospital. I always enjoy reading stories of the births she attends.

Sometimes I attend a birth that reminds me how different my experience is than many hospital providers. This birth was very powerful and beautiful, and reminds me again how awesomely powerful women's bodies are. It was not an easy birth, but the hard parts were still handled by the mama and her baby with amazing power and just a little help. I know that most hospital practitioners have never seen a birth like this - and I wonder how my view of birth would be different if I never had either.

B. is another one of my teenage clients. Unlike many of my teen moms that come of difficult backgrounds, B. was an excellent student, with loving, supportive parents. B.'s pregnancy was a huge shock to her family, and to her large circle of loving family friends. The circle of friends includes the family that are executive directors of the maternity home I often do prenatal care for. This family had known B. since birth, and despite their career being focused on caring for women with unintended pregnancies, B.'s was still a big shock. Family and friends both recovered well from the initial shock, and B.'s mom especially was very supportive and wonderful throughout the pregnancy, attending all her visits and being happy about the baby, even though she was disappointed about the timing.

B. was sort of a high maintenance pregnant client. She'd obviously been the petted baby of her family, and reacted strongly to all the discomforts of pregnancy. She had quite a number of unscheduled visits for belly pain, back pain, nasal congestion, pelvic pressure - you name it. She had multiple visits to labor and delivery for pre-term contractions (never true pre-term labor.) Her family, and even her boyfriend, always responded to her with loving concern, and attempts to make her feel better. I have to admit to getting a little frustrated with her - but did my best to keep it to myself.

During the third trimester, B. "studied" childbirth with a couple of family friends. Both of them had taken a Bradley class, and they went over their work book and notes with her. She also borrowed several books from me, and wrote a term paper in her junior English class on the risks of epidurals. She wrote a birth plan that looked very Bradleyish, and included not wanting to be induced and not wanting any pain medicines. Having at this point seen her in tears so often due to back pain, or Braxton Hicks contractions, I privately wondered about this birth plan - was it hers, or the friends? The one friend had a lovely unmedicated VBAC with me 3 years ago and she and her mother (who is the executive director of the maternity home) planned to be at the birth as support people.

As B. approached her due date, she stopped complaining about contractions. She joked about how ironic it was that she'd had them for months and now they were gone when she wanted them. Her due date passed, with no interest on her part in induction - she never even mentioned it, despite mentioning often how much she wanted to see her baby. At 41 weeks, she was scheduled for a biophysical profile. B. called on the way to the ultrasound to say she was having a little bit of pink tinged mucus when she wiped. By the time the ultrasound was done and she went up to labor and delivery for the NST portion, she was still having a little bloody show, and now having some irregular contractions as well. She asked a labor nurse to check her. The nurse called (my favorite nurse again) and said she thought B. was trying to start laboring. She was 1 cm dilated and 60% effaced, with irregular contractions (about 10 o'clock in the morning.) The ultrasound, however, showed a decent sized straight posterior baby. The nurse told me she'd suggested that B. go home and spend as much time on hands and knees as she could stand, and try to get this baby to turn around. She had appointment with me later in the afternoon, and planned to keep it.

Around 3 pm, B. came for her appointment. She told me the contractions had slowly been getting stronger and a little closer together all day long. She also told me she'd been crawling around as much as she could, and had her mom rubbing her back and was feeling contractions mostly in her back. She asked me if I'd check her again. During the visit, she had 3 strong contractions, and during the 3rd one, she started to cry, and when her mom asked her what was wrong she said "This just hurts so much!" I checked her a few minutes later, and she was now 3 cms and 80% effaced. B. was cheered up that she was actually making change. To my surprise, she said she wasn't ready to go to the hospital yet. I suggested she go home, eat supper, take a soak in the tub, a nap if she could manage it, and that I guessed she'd be back to the hospital later this evening. Her boyfriend was due to give a speech in a college class that evening, and decided to try to still get there to give it, while her mom planned to stay with her.

Around 8 pm, B. arrived back to the hospital. At this point, her contractions were every 3 minutes, and she was breathing hard with them and having a lot of pain and pressure in her back. Her whole support team arrived with her - boyfriend (who'd gotten an A on the speech), mom, dad, family friends (the mom and daughter who were to be her designated labor support) The nurse called me and said B. was now 4 cms dilated and 90% effaced, and contracting regularly. I came in to see her at this point. B. was bouncing on the birth ball when I got there, and one of the friends was kneeling on the floor pushing on her back. B. was obviously working hard now, but excited that she might soon see her baby. Although she mentioned that she was hurting, she also seemed calm and determined, and although she asked for the support she needed ("Rub my back!" "Where's my drink?" "I'm hot!") she didn't talk about pain medicine.

For the next few hours, B. got in and out of the tub (we were having issues getting it hot enough, so she'd stay in until she was cool, then get out while we drained and refilled it) walked in the halls, bounced on the ball, drank juice, and leaned on her support team. For a long while, the contractions seemed to stay about the same, and then, they started to become less frequent instead of more frequent. B. started to be tired, and crabby, and struggled to stay on top of contractions. She'd not wanted a lot of cervical exams, so we kept trying to help her be comfortable. Finally, around 2 am, when B.'s contractions were only about every 7-8 minutes now, and she was falling asleep between them and waking up struggling to cope with them, I asked her if she wanted a cervical exam, and she said she did. I checked, and she was still 4 cms dilated, and 90% effaced. B. was really discouraged at this point. She'd now been laboring since about 7 in the morning, and had had absolutely no change since arriving to the hospital 6 hours ago.

We discussed options at this point. First of all, I told B. that her baby was fine, she was fine, she was coping beautifully and keeping up her hydration, peeing well, and overall doing great - so there was no medical need to do anything at this point. We could just wait and see what happened. I suggested if she wanted to wait, that we try dimming the lights, and tucking her up on her side in bed with all kinds of pillows for support, and she see if she could rest. She was exhausted at this point, and sometimes dozing off between contractions. Second, if she didn't feel like resting was an option, and she didn't want to just continue waiting, we could try something to augment her labor - either AROM or Pitocin. She asked a lot about what either intervention would mean. (Pitocin would mean continuous monitoring, and being stuck to the IV pole - AROM would commit her to delivery, might make contractions more painful, and might encourage the baby to stay in a poor position - but would leave her with the freedom to still move and be off the monitor,) She cried a little at this point, and said she was just so tired, and scared, and not wanting to hurt anymore. Her mom, who is very emotional, cried too, and said she felt so helpless to help her daughter feel better. Her dad, the boyfriend, and the family friends were all for AROM, wanting to get this show on the road. Seeing her distress, I suggested that she try just resting for a while, that there was no need to make a decision right now, and she calmed down and said she'd try that.

A few minutes later, at about 2:15 am, we had her tucked as comfortably as we could on her side, with pillows under her leg and arm, and mom rubbing her lower back still. We turned off the lights, and the nurse and I told her we'd be right outside the door if she wanted us. For 30 minutes or so, she was quiet, and we hoped she was able to sleep a little. Then, we started to hear her moaning through contractions and breathing hard again, although the contractions were still 7-8 minutes apart. Finally, around 3:15 am, her dad came out of the room and said B. would like to talk to me.

B. said again that she was so tired, and just so worried that doing anything would make her hurt more. I told her honestly that it may well make her hurt more - but I was also a little worried that she was so tired now, that if we waited a few more hours and she was still unable to rest that she would just be that much more tired and still in the same position. I assured her again that she didn't have to make any decision urgently, because she and the baby were fine. She thought for a moment and said she thought she'd like to try having her water broken. I checked her again - still 4 cms, 90% effaced, 0 station - and hooked her membranes with an amnihook, and clear fluid spilled out. B. had been lying in bed at this point, but the very next contraction, she sat straight upright, called for her friend to rub her back, and rocked back and forth. "That was much stronger!" she said, "I can't do this lying down!" We encouraged her to get up, and the next few contractions, which came faster and faster, she walked in the room, and leaned over her mother during a contraction. Soon, she was breathing harder, moaning through contractions, and saying this laboring stuff was not much fun. She wondered if getting in the tub would still help, and we decided to find out.

Once B. was soaking in the tub again, she was smiling some more. Contractions continued to come every 3 minutes or so, but she felt less pressure and less and less discomfort in her back. Since she was more comfortable, and anyway had such good support, I decided to lie down for a bit. By 4:15, I was snuggled in a recliner with some blankets from the blanket warmer and was able to doze. I slept fitfully off and on until the nurse woke me at 5:45. "B. is pushing a little with contractions, and she wants you" she said.

Back in B.'s room, the scene had taken on a much more intense feel. Somewhere along the line B. had shed all her clothes. She had the external fetal monitor strap on, and not one other thing. She was standing up, and during a contraction leaned forward holding up hanging from her mom's shoulders, and the friend was rubbing hard on her back (the friend later told me she was sure she'd left bruises since B. wanted such hard rubbing!) B. was sweating, and breathing hard. "Please, can't I just push?" she wanted to know, and I asked her if she felt like pushing. She said not really, but she just wanted it to be over. I suggested she just wait until her body started pushing. She reached out and grabbed my arm and said "Then please, won't you give me some pain medicine?" This was the first I'd heard her mention it since she walked in the door. I tried to talk to her about it - saying I thought she was close to having her baby, but she just kept saying "oh please, please do something!" Her support people (who've attended many births) both suggested that she was in transition, and tried to remind her what that is like. Her mom started to cry again, and said it was just so hard for her to see B. in pain. I had to agree it was hard to see her hurting and wished there was something to do for her. I told her we'd have to do an exam if she truly wanted pain medicine, and she willingly flopped down on the bed and said "Just check me then!" I did - but she was 8 cms or so dilated, with the cervix just stretching away during the exam, and the baby's head descending through it. Too late for IV pain meds, and even an epidural might not make it in time. Hearing this news, B. said again she did not want an epidural, so just forget it!

B. hopped back out of bed immediately, and went back to leaning on her mom. She was still working hard, but looked determined again. She'd snap at whoever was rubbing her back "Harder! Don't stop!" and snap at the boyfriend to bring her drink right now. After 10 minutes or so, she suddenly plopped down on the floor - completely naked, leaking amniotic fluid all over, sweating, breathing hard - flat on her rear end on the floor. Her mom sat down behind her, and soon she flopped backwards into her mom's lap. Mom sat cross legged, and B. laid with her upper body in mom's lap, curled her arms around mom's arms, and rolled back and forth with contractions. We could easily see each contraction build across her belly, and almost the outline of the baby since she was thin to begin with. After just a few contractions, she said she was having more pressure in her butt, but still no real urge to push, but couldn't I just check her again and couldn't she try to push the baby out anyway. And furthermore, she was not getting off this floor, couldn't I just get down here on the floor and check her anyway?

I can get on the floor of course, and after convincing her to at least slide a clean bed pad between her rear end and the (possibly yucky) hospital floor, I did a quick exam. Tiny anterior lip, with the baby pretty much through the cervix. B. said she just wanted to try to push, and I encourage her to wait for a true urge, but didn't think she'd hurt anything by pushing. Lying in her mom's lap with her arms curled under and gripping mom's arms, B. pushed with the next contraction. For the first couple contractions, she pushed in short bursts, or just grunted a little. Even so, we could soon see the outline of the baby's head bulging the perineum. B.'s mom's leg fell asleep, and she asked B. if she could move, and B. snapped "Don't you dare move!" The mom took a deep breath and held as still as she could. After a couple more contractions, B. said her tailbone hurt, and I asked her if she wanted to move. "I am NOT getting in that bed!" she said with a serious glare. I meekly replied that I just meant maybe she could try squatting or kneeling and get off her tailbone. She thought for a moment and said she'd try that.

B. slowly turned over - it taking quite a bit of effort to get off the ground at this point. She made it over to her knees, and I suggested she hold on to the bed. Her boyfriend lay down across the bed with his head at the side of the bed, and she knelt at the bedside, holding his forearms for support, and resting her head on his shoulder. He whispered encouragement to her - and told her he was sorry for doing this to her - and she held on to him for dear life. The poor mom finally made it to her feet with her asleep leg, and the support people moved to supporting the mom, who was just overwhelmed at the intensity of it all at this point. B.'s dad had been in and out of the room, and now was back in, but in the corner of the room. He could see B.'s head over the bed, but not the rest of her. The mom and the 2 friends stayed behind B., wanting to see the baby. Shift change happened just then, and the 3 new nurses joined the 2 I already had in the room. I knelt on the floor next to B. Although it sounds like a huge crowd, it was very quiet and intense in the room. The only sounds were B. working hard, and her boyfriend encouraging her, and the nurse or I telling her how wonderful she was doing. Within just a couple pushes, baby's head was staying visible even between pushes.

With the next contraction, B. slowly pushed her baby's head out, and mom started to cry, dad across the room started to cry, the friends cheered, the boyfriend started to cry. Even though B. was kneeling on the floor, I could see the baby's head emerge, and then almost look sucked back against the perineum - a turtle sign that immediately made me think of a shoulder dystocia. Baby was LOA, having turned I think somewhere late in labor. I waited for B. to take a few breaths, and asked her if she could push again, and she started to push. The baby didn't move at all and her face suffused with purple while B. pushed. I reached for the head and pushed up gently to see if the anterior shoulder would be freed - but it didn't budge. While B. pushed, I switched directions and tried to free the posterior shoulder - but it didn't budge. B. took a few more breaths, and when she started to push again, I lifted the head up again, and with a slight popping sensation, the baby's anterior shoulder came free, and almost immediately the whole baby slid out into my hands. There were 2 tight wraps of cord around the neck, but baby splashed right out. B. heaved a huge sob of relief and dropped her head and shoulders down on the bed. One of the nurses squatted on the floor with me and unwound the cord, and dried the baby's face as she coughed a couple times, and then started to cry. With the first cry the whole room erupted into laughter and tears and whoops of joy.

Within a minute or so, B. was looking around for her baby. A nurse threw a clean pad down on the bed, and B. stood up, lifted her leg up while I passed the baby under to her hands, crawled onto the bed holding the baby, and sat cross legged on the bed holding her baby to her chest. (Only teenagers are that athletic in the minute after birth!) Her boyfriend wrapped his arms around them both, and we put a couple warm blankets around them all, and everyone sort of stepped back and breathed some sighs of relief ourselves. Baby was born at 7:17 am, about 24 hours after labor started, 11 hours or so after she'd come to the hospital, but just 4 hours after she'd been 4 cms and had her water broken.

After a while of sitting and holding her baby, B. started to feel more cramping and more uncomfortable and wanted to get the placenta out. She lay back on a few pillows, still holding her baby to her bare chest. We clamped the cord, and the boyfriend cut it with shaking hands, while everyone else took pictures. B. pushed once, and the placenta was out. While B. was pushing the baby's head out, since she was kneeling and leaning forward, I could easily see her perineum. The head had slid out slowly and atraumatically and I didn't think she'd had any tears at that point. However, as the shoulders came, there'd been a sudden little gush of blood, and I worried that the popping sensation as the shoulder came was a perineal tear. Sure enough, I could see a midline tear. At first, I though it was just the skin, but as I tried to follow it downward, I couldn't quite see the base of it. Worried about the extent of this tear, I decided to take apart the bed and put B.'s legs in the foot pedals and get decent light to see what was what.

Unfortunately, the tear turned out to be a partial 3rd degree laceration. The sphincter capsule and muscle fibers hung loose in the middle. I explained to B. that she would need some local anesthesia and stitches. This sounded like a just terrible idea to her at this point, but I was able to inject the local pretty much without her feeling much (sometimes the vagina and perineum are numbish from the stretching of the baby and overload of the nerves.) While B. snuggled her baby, and drank a Sprite lying down, I repaired the sphincter, then the perineal muscle layer, then the skin. The tear didn't go quite all the way through the sphincter, and the rectal mucosa was all intact.

Soon, we were done, and B. wanted to have the baby weighed. This skinny 17 rd old had managed to push out an 8 lb 13 oz baby girl - in less than 30 minutes! I asked B. if she was upset about not getting pain medicine and she said "Heck, no!" and that she'd have been very disappointed if she'd gotten pain medicine that close to the baby's birth after getting through all that labor on her own. We helped B. put the baby to breast, and cleaned up the room. B.'s baby mostly did not leave her arms for the next 24 hours, but snuggled with her mama, and nursed, and was loved. The next morning, the nurse who came on in the morning did her assessment exam - and was shocked to find crepitus over the right clavicle, and the baby wincing whenever she touched it. An xray showed that her right clavicle was broken. Looking back, I'm sure that was actually the pop I felt as the shoulder came free. Fortunately, babies' clavicles heal easily, and she has no nerve damage or other problems and just needs to have no one pull on her arm while she's healing. B. felt great, despite the long labor, the extensive perineal repair, and the lack of sleep. She positively glowed while describing her birth - and was so in love with the baby.

See, the thing about this kind of birth is that this mama had it in her to do it. All she needed was the space to do it in. She just needed folks around her to believe she could. It was not an easy birth, or a short birth, or an uncomplicated birth. It was ordinary and yet sacred, moving and extraordinary. Mostly, we just encouraged this young mama to do what felt right to her, and she took the powerful, primal energy of birth and used every bit of it to make it hers. Watching her, who'd seemed so young and vulnerable and needy, turn instead into someone powerful, and strong, and even commanding was an amazing thing. When she was hurting, she didn't need me to rescue her or feel sympathetic, she just needed me to trust her and give her the space to keep going.

So: What if you attended births, but you never saw a birth like this? What if instead your system encouraged, or even coerced, needy, opinionated teenagers like this into lying in bed, strapped to a monitor, until they were overwhelmed? And then you talked them into an epidural to make them comfortable? What if their birth plan was treated as the hubris of an inexperienced child and laughed at? What if her request for limited exams was seen as childish and responded to with "You were able to open your legs to get this baby in there!" type comments? What if she'd pushed and pushed, but her baby had been wedged posterior by the epidural, and her sacrum couldn't move squashed against the bed and the baby never came out? Or she did come out, but the sticky shoulders in hands and knees was a full blown shoulder dystocia in semi-sitting and she'd had a huge episiotomy and a brachial nerve palsy, or worse brain damage from lack of oxygen? Then you'd say "Those damn teenagers think they know what they're doing. Can you believe she thought she could do this? Thank God we saved her baby!" And knowing you were right about it all, you'd treat the next client just the same. Occasionally, you'd see some quick birth happen before you could intervene much, but those would be chalked up to luck, and the rest would have the full gamut of technology you can provide.

I've seen that alternate birth story during my training. I've heard it told to me by friends and clients who birthed elsewhere. I'm always so grateful when I get to witness a birth like this, a birth that took a woman to the limits of her abilities, but she stretched herself and did it. These are the births that keep me going, that I remember in middle of night awakenings, that remind how strong women are, that I wish every birth attendant would be required to witness.